Update Payment Information | Northern Ohio Health and Wellness

Please update your payment information.

If you have any questions don’t hesitate to call us at 216-440-2936.

Update Your Credit Card Information

Name of Therapist

Patient Name

Name on Credit Card

Type of Card (Visa, Mastercard, Discover, Amex, etc...)

Credit Card Number

Expiration Date

3 Digit Code (CVV)

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Email

Consent

I agree to the financial policy.

A credit card is REQUIRED for all clients to cover any outstanding balances pending issues with insurance coverage or cancelation fees with less than 48 hours notice. Please be sure to fill out completely and list a valid e-mail so you can be contacted prior to the card being charged for any balance due, or to hold your therapy spot, as well as e-mail your receipts.

Delinquent Accounts. You understand that you are responsible for all charges incurred and that services must be paid in full at the time of each visit. We will not be able to continue therapy until accounts are current to ensure that Northern Ohio Health and Wellness can continue to provide quality therapy to our clients. Should your account become delinquent, you agree to pay interest at 5% per month, and if it becomes necessary for the account to be referred for collection action, you agree to pay the actual balance due plus any collection expenses of 30-50% of any balances owing, and any attorney’s fees.

Standard Notice: “Right to Receive a Good Faith Estimate of Expected Charges”
Under the No Surprises Act

Under Section 2799B-6 of the Public Health Service Act and its implementing regulations, health care providers need to give patients who don’t have certain types of health care coverage or who are not using certain types of health care coverage an estimate of their bill for health care items and services before those items or services are provided.

- You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services.

- If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a health care item or service at least 10 days in advance, make sure your health care provider or facility gives you a good Faith Estimate in writing within 3 business days after scheduling. You can also ask any health care provider or facility for a Good Faith Estimate before you schedule an item or service. If you do, make sure the health care provider or facility gives you a Good Faith Estimate in writing within 3 business days after you ask.

- If you receive a bill that is at least $400 more for any provider or facility than your Good Faith Estimate from that provider or facility, you can dispute the bill.

- Make sure to save a copy or picture of your Good Faith Estimate and the bill.

For question or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurpries/consumers, email FederallPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059

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