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Financial Responsibility Agreement

This Financial Responsibility Agreement (the “Agreement”) is made and entered into between Heal it in the Wild LLC, and its affiliates under common control or ownership (“Heal it in the Wild LLC”), and the client receiving mental health services or their personal representative (“You”). 

 

BY CHECKING THE BOX “I AGREE” YOU INDICATE YOU HAVE READ, ACKNOWLEDGE AND AGREE TO THIS FINANCIAL RESPONSIBILITY AGREEMENT. IF YOU DO NOT AGREE TO THESE TERMS, YOU CANNOT ACCESS OUR SERVICES AND MUST EXIT NOW. 

1. Your Responsibility for Payment: Individual Therapy. You are responsible for payment for all services provided by Heal it in the Wild LLC. Each payment will occur within 24 hours of your scheduled appointment.

    Your Responsibility for Payment: Drop-In Hikes. You are responsible for payment for all services provided by Heal it in the Wild LLC. Each payment will occur at the time of registration.

     Your Responsibility for Payment: Hike Membership. You are responsible for payment for all services provided by Heal it in the Wild LLC. Each payment will occur on the 1st of every month. If the 1st falls on a weekend or holiday, the charge will occur the weekday prior.

     Your Responsibility for Payment: Retreats/Camps. You are responsible for payment for all services provided by Heal it in the Wild LLC. Each payment will occur at the time of registration. If payment plans are offered, each payment will occur on the 1st of every month. If the 1st falls on a weekend or holiday, the charge will occur the weekday prior.

 

2. Services Covered by Insurance. Heal it in the Wild LLC will use the insurance information on your file to bill for services, as applicable. You understand that insurance payments from the insurer for services rendered by Heal it in the Wild LLC may be addressed and sent directly to you. In such an event, you agree to endorse and mail any payments and corresponding explanations of benefits to: Heal it in the Wild LLC, 4004 Tine Roof Way, Glen Allen, Virginia 23059.

3. Cancellations and No-Show Fees: Individual Therapy.  If you cancel within the twenty-four (24) hours before the appointment, or if you fail to cancel the appointment and do not attend the appointment, you may be subject to a cancellation fee, up to the full cost of the session at the then current self-pay rate. 

    Cancellation and Refund of Fees: Hiking. You must cancel 48 hours prior to a hike in order to receive a refund for DROP-IN Hikes Only. If you cancel within the 48 hours before the drop-in hike, or if you fail to cancel registration for the drop-in hike and do not attend the drop-in hike you will not receive a refund for your registration. If you would like to cancel your hiking membership, you must do so with a months notice. You may contact hello@healitinthewild.com to cancel your hiking membership. Once a hiking membership has been billed for the month, no refund will be given. However, with a months’ notice, your membership will be cancelled and no further payments will occur.

      Cancellations and Refund of Fees: Retreats/Children’s Camps: You must cancel two months prior to the event in order to receive a full refund of your registration fees. If you cancel a month prior to the event, you will receive a 50% refund of cost of registration. If you cancel any later than a month prior to the event, you will receive no refund.

4. Billing. After your insurance provider(s) have processed the associated claim, Heal it in the Wild LLC notifies you of any outstanding balances such as copays and coinsurance, appointment cancellation and no-show fees. The credit card on file is charged seventy-two (72) hours from the notice. 

5. Your Information. You agree to provide and update Heal it in the Wild LLC with accurate personal information including but not limited to contact information, insurance information, and debit/credit card information. Your failure to update this information may result in inaccurate charges or delayed refunds.

6. Collection Fees. In the event you have not made alternative arrangements for payment and this account is placed with an attorney or collection agency, you are responsible for collection fees, attorney’s fees, and court costs.

Collection Fees: Hikes/Retreats/Camps: In the event that payment is unable to be made for costs due for hiking memberships, retreats, or camps, you will be contacted three times for payment to be updated. If we are unable to reach you regarding payment, your registration to events will be cancelled. If this occurs within two months of a retreat or camp, you will receive a refund of all previously paid costs. If this occurs within one month of the event, you will receive 50% of all previously paid costs. For hiking memberships, you will have your membership cancelled and all access to events, hikes, VIP access, and VIP Facebook will be cancelled. If payment is updated and all past due fees have been collected, you will be provided access back to all previous services.

7. Credit Card Authorization.  You understand that Heal it in the Wild LLC will charge your credit card on file for financial responsibilities in connection with your care and treatment, including but not limited to any remaining balance, service fees, registration fees, membership fees and appointment cancellation fees. THE CARDHOLDER NAMED ON THE CREDIT CARD ON FILE WITH HEAL IT IN THE WILD LLC IS ULTIMATELY RESPONSIBLE FOR THE PAYMENT OF ANY OUTSTANDING BALANCE ON YOUR ACCOUNT. 

8. Right to a Good Faith Estimate. If you are not enrolled in a health benefits plan, or choose to not use your health benefits to pay for therapy services with Heal it in the Wild LLC, you have the right to receive a Good Faith Estimate for the total expected cost of services. Please submit your request for a Good Faith Estimate to hello@healitinthewild.com. If you receive a bill from us that is at least $400 more than the Good Faith Estimate, you can dispute the bill by emailing hello@healitinthewild.com. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

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