Auto-Pay Appeal

"*" indicates required fields

Auto Pay - Credit Card on File Policy: Payments are due at the time service is provided. Renewal Christian Counseling Center, like many other healthcare agencies, implemented a credit card on file policy due to the increase in virtual Telehealth appointments to collect payments whether your session is in-person or via Telehealth. The information will be held securely to be used to pay balances on your account such as deductibles and copays. You will receive a text notification automatically within 48-hours of your scheduled appointment.

* NOTE: Fees apart from normal services such as insurance rejections, no-show late fees, bounced checks, etc will not automatically be charged.

We also understand that there are circumstances in which other arrangements will be requested and this form is your formal request for exemption from this policy.

Reason for Appeal*
What's your recommended solution for payment for services?*

*** FOR OFFICE USE ONLY ***

This field is for validation purposes and should be left unchanged.
Copyright 2020 © Renewal Christian Counseling Center