3rd PARTY FINANCIAL RESPONSIBILITY AGREEMENT
The following is a Financial Responsibility Agreement for those individual’s or agencies who have elected to sponsor a client’s counseling expenses with MCO. It is important to understand the financial responsibilities and policies set forth by MCO.
I hereby authorize Paraclete Ministry Group LLC, dba MyCounselor, to automatically bill the card I have provided to MyCounselor. I guarantee and warrant that I am the legal cardholder for this credit card and that I am legally authorized to enter into this agreement.
I authorize Paraclete Ministry Group LLC, dba MyCounselor, to automatically initiate either an electronic debit or to create and process a demand draft against my bank account using the routing and account number I have provided. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.
I understand that if I fail to give notice of cancellation or rescheduling requests by using the scheduling software link, calling 855-755-3797, or emailing firstname.lastname@example.org at least 24 hours before my scheduled appointment I am responsible for the full fee of my session and my account or credit or debit card or checking account will be charged for the time I have requested to be reserved for me. I understand that I may not schedule, reschedule, or cancel appointments for other adults.
Memberships may be canceled at any time. Accumulated session credits on your account are non-refundable and will expire 12 months from the time of your cancellation. The scholarshipped person may continue to use accumulated session credits after membership cancellation and prior to their expiration.
Please give the name or names of the individuals being scholarshipped in the field(s) below.
When you have read this document please electronically sign it below. Your signature indicates you have read and understood the conditions as read and agree to receive services under these conditions.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: 3rd PARTY FINANCIAL RESPONSIBILITY AGREEMENT
Agree & Sign