Autopay Enrollment

Accepted Payment Methods: Visa, MasterCard, American Express, Discover, Health Savings Accounts
Starting August 19, 2019, we will be requiring a credit card on file for all patients to collect any co-pays, co-insurance, no-show or same-day cancellation fees. Our policy requires 48 hrs notice to cancel or reschedule an appointment, unless in cases of an emergency or hospitalization, or a $100 fee will be applied.
What is the reason for this?

First of all, our patients have requested it because it is more convenient. Patients wanted to not have to remember to pay their bill after each appointment. Also, you won’t have to worry about late payment fees (which can be up to $50) if you enroll.

This works just like other professional’s offices, hotels, or rental car companies. You will receive advanced notification of any charges determined to be patient responsibility either by our clinic or your insurance. You will receive a letter in the mail (or email) from your insurance that explains how much of your office visit they paid, and how much you are responsible for. This is called an Explanation of Benefits (EOB). It arrives after your appointment has been billed.

What if I need to dispute my bill or EOB?
We will always work with you to understand your bill. We will always assist in the correction of any potential mistakes. We will refund your credit card if we or if your insurance has made a billing error. We will only charge the amount that we are instructed to by your insurance carrier, in the EOB they sent to us. No shows and late fees are not covered by insurance.
What if I do not wish to provide my credit card online?

If you do not wish to enter your credit card information below, here are some alternatives:

  • Prepay for the full cost of the visit at least 2 business days in advance to secure the appointment. To do so, you can send the out of pocket cost of the visit via Zelle by using the ‘send money’ feature through your bank (most banks use Zelle) and send it to Bruce Bassi, admin@telepsychhealth.com To check if your bank is compatible with Zelle: https://www.zellepay.com/get-started We can then refund you for the overpayment after your insurance has evaluated the claim.

  • Provide your card information by phone to us directly at 888-730-5220

Will my card information be secure?

TelepsychHealth does not store your payment information, but it is stored in a secure third-party payment gateway that specializes in storing this information. The form below sends the information directly to the gateway and we later interface with the gateway. To learn more about the security of your card information visit https://www.bluefin.com/support/

Autopay Consent

I authorize TelepsychHealth to automatically charge the debit or credit card below, the amount due on my account following appointments with providers, including any copay, coinsurance, no-show, or same day cancellation charges ($100 unless in emergencies).

I understand that TelepsychHealth will initiate transfers/charges according to this authorization and agreed upon appointment charges not to exceed the amount on my balance. If I notice a discrepancy in the amount charged to the amount on the balance, I can contact TelepsychHealth to determine the appropriate charge; a refund can be issued, or the balance could be applied as a credit to future visits.

I authorize TelepsychHealth to charge my debit or credit card for all delinquent amounts owed to TelepsychHealth.

I may contact TelepsychHealth by phone or email to request that future payments be changed or discontinued. TelepsychHealth will not make charges to my credit or debit card after I have cancelled.

I understand that by entering my information below, I acknowledge the terms set forth in this agreement.

If the name of the card holder is different from the patient’s name, you may still submit your information, but please send us a message telling us who the patient is. You may also give your credit card information to us by phone by calling 888-730-5220.

Pin It on Pinterest