Payment Authorization
By your electronic signature of this form, you authorize charges to your chosen form of payment as compensation for services rendered. These charges will appear on your bank/credit card statement as Healing Hydration, LLC. You have the right to request a copy of the invoice.
You understand if Venmo, Cashapp, Paypal, Apple pay or any other online payment source is used and a dispute is filed on the charge, Healing Hydration, LLC will invoice you the full amount of service as well as any fees that are associated with the disputed case.
You understand if payment is not successfully received at the end of the service, you will be invoiced via email and mail. You understand that if no payment is provided at the end of service an additional $50 fee will be added due to non-payment. If no payment is received on or after 24 hours post-service, you understand that Healing Hydration's legal team will take over the process of collecting payment at that time. For each day that no payment is received, an additional $10 will be added on per day.
You authorize Healing Hydration, LLC to charge the credit card that is on file for services that are provided. If multiple cards are put on file for use, Healing Hydration, LLC will charge the preferred card on file unless instructed otherwise.
A 48 hour’s notice must be given if you are not able to make your appointment. If you cancel within 48 hours of the scheduled appointment, 50% of the scheduled service will be charged to the credit card on file. You can reschedule their appointment; but, ask that rescheduling occurs before 48 hours of original appointment time. If the appointment is canceled the day of the appointment, 100% of the visit will be charged due to lost revenue and taking a spot another patient could of had. If a clinician comes to location provided upon booking and there is no answer at door, 100% of scheduled services will be charged to the credit card on file. If no credit card exists on file, the patient will be invoiced at provided email address. If not response via email, a mailed invoice will be sent to the provided mailing address. A no show fee must be paid within 24 hours of invoice being sent. If the invoice continues to go unpaid, Healing Hydration, LLC's legal team will take over the process of collecting payment as well as a $50 late fee plus a $10 non-payment fee will be added for each day the fee goes unpaid.
You certify that you are the authorized user of this credit card and will not dispute any scheduled transactions with your bank or credit card company if the transactions correspond to the terms indicated in this authorization form. You acknowledge that credit card transactions could be linked to Protected Health Information.
You understand that this authorization will remain in effect until you cancel it in writing, and you agree to notify Healing Hydration, LLC in writing of any changes in my account information or termination of this authorization.
Please note:
You may pay for the services received in any accepted form of payment; however, a credit card is required to be on file prior to the clinician leaving to come for any home visits.
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