Credit Card Authorization

Path CCM, Inc. 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 “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 understand that it is the policy of Path CCM, Inc. and its affiliates that I maintain an active credit card on file prior to receiving any treatment services.

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.

Have questions? Email info@pathccm.com