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Credit Card Authorization

Path CCM, Inc. dba as Rula Health (“Rula”) provides management and administrative support services to SUD Specialty Group – CA, Mental Health Specialty Group, P.A., and Mental Health Specialty Group NJ, P.C. (collectively, "Group"). This form applies to Path CCM and its medical group affiliates listed above.

I hereby authorize Path CCM, Inc. to process the credit card as a "Card on File," and I understand that this authorization will remain in effect until the expiration of the credit card account for any costs associated with the services described in this Financial Responsibility Agreement. However, I understand that I may revoke this authorization at any time by submitting a written request to SSG.

I also understand that Rula may place a temporary authorization hold on the credit card on file to verify that the card is valid and operational. This authorization hold is not a charge and will be removed by the card issuer.

I, THE UNDERSIGNED, HAVE READ AND UNDERSTAND THIS FINANCIAL RESPONSIBILITY AGREEMENT. I HEREBY ACCEPT FULL RESPONSIBILITY FOR PAYMENT OF ANY FEE(S) NOT COVERED BY INSURANCE OR ANY FEES ASSOCIATED WITH SELF-PAYMENT OF SERVICES.