I, the undersigned individual, authorize CI MA, MD. INC, to charge my method of payment including credit card in the event that I fail to show for a scheduled appointment or do not notify Dr. Ma at least 48 business hours (2 business day) in advance if I cannot make an appointment, as agreed upon in the Office Policies Form. Furthermore, for outstanding payments on services rendered, I authorize Dr. Ma to charge my method of payment including credit card for the full amount due. I agree to not dispute charges for any of the above reasons. I further authorize Dr. Ma to disclose information about my attendance and/or cancellation to my credit card company if I dispute a charge. This form will be securely stored in my clinical file and may be updated by me upon request at any time.
*Please note your credit card will not be charged unless one of the following conditions occur:
(a) No Show for a scheduled appointment
(b) Cancellation less than 48 business hours (2 business day) in advance
(c) Participation in treatment, or services performed, without payment rendered.
Zelle Email: Ma.Macy.MD@gmail.com
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Checks by Mail
You are expected to pay for each session at the time of the appointment. Payment for other professional services will be agreed to at the time of your request for these services. A $25 fee is charged for all returned checks. If your account is overdue, Dr. MA reserves the right to use legal means to secure payment. This includes charging the on-file credit card as well as utilizing a collections agency or a small claims court. In such cases, required information which may contain confidential health information may be provided to these agencies, including name, nature of services provided and amount due. Furthermore, if the amount due is not paid in full, you agree to bear all collection costs, court costs and legal fees.
By signing below, I acknowledge that I am aware of Dr. MA’s professional fees and billing policy.