Consent for Recurring Credit Card Payments
I (“the patient”) agree to allow Eve Adam Health LLC. to securely store a credit / debit card (the “payment method”). The patient authorizes the payment method to be used automatically for any patient responsibilities for payment.
If a credit card account is being used for a transaction, Eve Adam Health LLC may obtain pre approval for an amount up to the amount of the payment.
If the patient wants to designate a different payment method or if there is a change in the patient’s payment method information, the patient must change the information online. This may temporarily delay the ability to make online payments while we verify the new payment information.
If the patient purchases a subscription to Eve Adam Health LLC products or services, the patient’s subscription is continuous and will be automatically renewed at the end of the applicable subscription period, unless the patient cancels his or her subscription before the end of the then-current subscription period by clicking here
If the patient cancels his or her subscription, the patient’s account will automatically close at the end of the current billing period. Eve Adam Health LLC may change the price for the patient’s subscription, from time to time and will communicate any price changes to the patient in advance and, if applicable, how to accept those changes. Price changes will take effect at the start of the next subscription period following the date of the price change.
If the patient cancels his or her subscription, the patient’s account will automatically close at the end of the current billing period. Eve Adam Health LLC may change the price for the patient’s subscription, from time to time and will communicate any price changes to the patient in advance and, if applicable, how to accept those changes. Price changes will take effect at the start of the next subscription period following the date of the price change.
The patient represents and warrants that (i) any credit / debit card information the patient supplies is true, correct and complete, (ii) charges incurred by the patient will be honored by the patient’s credit/debit card company, (iii) the patient will pay the charges incurred in the amounts posted, including any applicable taxes, and (iv) the patient is the person in whose name the credit / debit card was issued and the patient is authorized to make a purchase or other transaction with the relevant credit / debit card and information.
The patient agrees and authorizes the payment method to be billed automatically for the entire visit, according to the published pricing on the Eve Adam Health LLC website, which is subject to change at any time. If Eve Adam Health LLC is unable to secure funds from the patient’s debit / credit card(s) for any reason, including, but not limited to, insufficient funds in the debit / credit card or insufficient or inaccurate information provided by the patient when submitting electronic payment, Eve Adam Health LLC may undertake further collection action, including application of fees to the extent permitted by law.
The patient has the right to revoke this authorization by logging into their Eve Adam customer portal and pausing their subscription 8 days prior to their next scheduled renewal.
Agreement for Self-Payment of Services
Agreement for Self-Payment of Services
Our services are 100% self-pay by our patients. By signing this form, you acknowledge that:
you do not have any health insurance through a PPO, HMO, Medicaid or Medicare or any other insurance plan; or
you have health insurance but you do not want to use any insurance benefit for these services, acknowledging that Innovative Care does not accept any health insurance. Your insurance policy is a contract between you and your insurance company.
It is your responsibility to know your benefits, and how they will apply to your benefit payments, and we take no responsibility to understand or be bound by the terms and conditions of such insurance.
By signing this form, you are electing to purchase services that may or may not be covered by your insurance if you obtained those services from a different provider. You have selected services for purchase from us on a self-pay basis. In other words, you have directed us to treat your purchase of these services as if you are an uninsured patient and you agree to be 100% responsible for full payment of the listed price of the services. There is no guarantee your insurance company will make any payment on the cost of the services you have purchased.
Eve Adam Health LLC has provided you with the charges, in advance, for the services you have requested. By sliding the switch on the Eve Adam LLC website you agree to pay these charges in full as a self-pay patient, electing not to use an insurance policy benefit. You have been given a choice of different services, along with their costs. You have selected the services and are willing to accept full financial responsibility for payment.
