Credit Card Authorization Form
By electronically signing this form, you authorize Greater Change Health to charge your credit card through Stripe via SimplePractice for services rendered under the Greater Change Health Subscription Therapy Model. These charges will appear on your bank or credit card statement as Greater Change Health. You may request a paper copy of this document at any time. A month refers to Greater Change Health’s twenty eight day billing cycle.
Authorization of Charges
I authorize Greater Change Health to charge my credit card through Stripe for all fees associated with my subscription based therapy plan. The plan includes the following items.
Monthly Membership Fee. Seventy five dollars and ninety nine cents. Provides access to three therapy sessions per month.
Per Session Cost. Thirteen dollars and fifty cents for each of the first three sessions per month.
Additional Sessions Beyond the Third. Thirty five dollars and ninety nine cents per session.
Missed Appointment Fee. Seventy five dollars and ninety nine cents for no shows without prior notification.
Late Cancellation Fee. Thirty nine dollars and ninety nine cents for cancellations or reschedules made within twenty four hours of the scheduled appointment.
I understand that services begin on the date of my first scheduled session regardless of attendance.
Discounted Services Policy
If I receive discounted services through a promotion, discount code, or special arrangement and I miss, no show, or late cancel an appointment, my pricing will immediately revert to the standard fees listed above. This includes any session that was previously discounted or offered at no cost. Standard missed appointment and late cancellation fees apply to all discounted or free sessions. I acknowledge that all services are provided only within the Greater Change Health subscription model.
Insurance Disclaimer
If insurance does not cover any portion of my invoices for any reason, including denials, delays, or coverage limits, I remain responsible for the full outstanding balance. Insurance does not cover the monthly membership fee and may not cover session costs priced below standard reimbursement thresholds.
Cancellation and Termination Policy
This authorization remains in effect until I cancel it in writing. I agree to notify Greater Change Health in writing of any changes to my payment information or to terminate this authorization. If I cancel my subscription, I understand that access to therapy sessions will end at the close of my current billing cycle.
Billing and Disputes
I certify that I am an authorized user of the credit card provided. I will not dispute charges with my bank or credit card company if they align with the terms outlined in this form. I acknowledge that credit card transactions under this subscription model may involve Protected Health Information in accordance with HIPAA requirements.
Payment Recovery Policy
If a balance is outstanding or a payment cannot be processed during a session, Greater Change Health may continue attempting to process payment. This may include multiple smaller charges throughout the week until the full balance is collected. These attempts will not exceed the total amount due. I will be notified of payment issues or partial charges. This process ensures continued access to services while maintaining my financial responsibility.
Acknowledgment and Agreement
By signing this document, I confirm that I have read and understand the terms of this authorization. I agree to all charges described and acknowledge full responsibility for payment, including when insurance does not provide coverage.