1250 SE Maynard Road, Ste. 204
Cary, NC 27511


Ph: 919-371-4378
Fax 919-300-7943

www.slteletherapy.com

 
 
​​​​Dear Silver Linings valued client:  

Due to the continued recommendations from the Center for Disease Control (CDC), and our continued concern for the safety of our clients, we have permanently mandated some necessary changes.

To maintain a hands-free and safer environment Silver Linings is asking all clients to have a credit card on file to cover the cost of co-pays, co-insurance, self-pay, deductibles, no show fees ($40.00) and any other monies owed for services provided.  Please fill out the linked form.  By filling out the form, you agree to have your credit card charged for the above.  All credit card information will be kept confidential and safe.  Your credit card will be billed during the second week of each month for any and all monies owed to Silver Linings per your Explanation of Benefits (EOB) from your insurance company(s).  After your credit card is billed, you will be emailed a receipt within 48 hours.

Although having a credit card on file is not required to be a client of Silver Linings, it is strongly encouraged and greatly appreciated.

Sincerely,




Ann Marie Sochia
Chief Executive Officer
Silver Linings

Credit Cards on File will be used for:

Copays/Deductibles/Outstanding Balances- When services are rendered, you will have the option to use the credit card on file or if at any time you want to use another form of payment, please notify the front office.  This authorization will remain in effect until you notify Silver Linings in writing of any changes to your account information and/or termination of this authorization.
 
Missed Appointments- If you miss more than one appointment without calling 24 hours in advance, it is Silver Linings policy to charge the missed appointment fee of $40.00 which is not covered by insurance and cannot be submitted to your insurance carrier. 
 

All patient responsibility amounts, as determined by insurance, will be reviewed by the Silver Linings billing department to ensure your claim has been properly processed.  Members typically receive their explanation of benefits prior to the provider, so if you disagree with the patient responsibility amount owed, it is your responsibility to contact your insurance carrier immediately. 

If at any time the credit card on file expires or otherwise becomes uncollectable, we will expect you to promptly provide a new means of payment.  If one is not provided, you are still responsible for bill payment in full.

We do our best to verify your benefits prior to the appointment to make sure we collect the appropriate amount owed and to make sure your visit will be covered by your insurance plan. However, it remains the policy holder’s responsibility to know their insurance benefits. Ultimately, you are responsible for knowing what services are covered, how often, and how much of the cost is your responsibility.  You will be responsible for any portion of services that your insurance deems is your responsibility.
 
 
 
CREDIT CARD PAYMENT AUTHORIZATION
Please complete all fields. You may cancel this authorization at any time by contacting us. 
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 
Credit Card
 
  


Billing Information
 
 
 


I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Silver Linings for Seniors, Inc. in writing of any changes in my account information or termination of this authorization.  I the client or authorized representative (financial/Power of Attorney) certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

Signature Instructions:
Touch Screen: use finger or stylus to sign
Desktop Monitor: use mouse or touchpad to sign


AUTHORIZED/POWER OF ATTORNEY SIGNATURE: