CURRENT CLIENTS —UPDATING A PAYMENT FORM

Credit , Debit or Health Savings Account Card

Full Name on Card

Full Name --as it appears on the card

First Name

Last Name

Email

Your email address

Type of Card

Type of Card (ex HSA, Mastercard, etc...)

Number on credit card

CVV

Expiration date of card

MM

DD

YYYY

Address

Full address that is associated with the card.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

First Name of Client for Whom Payment is Authorized

Please indicate name of the client for whom this card can be utilized (self, child, spouse, etc...)

First Name

Last Name

Text Area

I am accepting responsibility for payments on behalf of myself or another by submitting this payment information. This may include a deductible, co insurance, or copays, or the full amount of each session. If I have questions I may reach out to Metta for an expectation of charges that may apply.

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Relationship of Client to Cardholder. Client is my....

Self

Child

Relative

Spouse or Partner

Friend

Other

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I agree to be responsible for payment of all services rendered.

Agree to keep a card on file and to pay for all services rendered that are not covered by my insurance policy.

For your convenience you may add a new card anytime via the secure link above for copays, deductibles, or out of pocket expenses. If you’d like to talk with a human please reach out to Chris@MettaAZ.com with any questions or to share this information with our billing office.

Becoming a New Client and Completing Forms

**All of our CLINICAL and ADMINISTRATIVE forms can now be completed via secure direct electronic submission.**

To see if Metta is right for you before doing so, please request a personal call through phone, text, or email.

520-400-4747 or Elizabeth@MettaAZ.com (click links to connect)

Name

First Name

Last Name

Email

Phone or Text

(###)

###

####

Message

Best time and way to reach you.

Please speak directly with our Client Concierge, Lizzy regarding our services.

If you receive services our first several sessions help to determine if our team can effectively meet your needs and is considered an initial personalized clinical assessment to help determine the most appropriate care. We may refer you to other specialists or to a higher level of care if needed, or help you connect with the best provider for you within our organization.

We are a busy practice and do our best to match your unique needs and schedule with our clinicians’ availability and expertise. We are not able to accommodate all requests—however we try hard to return calls and have a 1:1 conversation with each person.

If this is an emergency please dial 911 or go to your nearest Emergency Room as we do not provide emergency services.

Tucson’s warm-line is: Local crisis number: 520-622-6000 In Maricopa County dial: 602-347-1100

Insurance Information

We work hard to accept a number of forms of insurance to help make psychotherapy affordable. Please speak directly with your carrier to be aware of your annual deductible, behavioral health benefits, co-pays or co-insurance obligations and so you fully understand your benefits for behavioral health.

If you have insurance on file we can bill insurance directly, and generally you will only be responsible for a deductible , co-pay, co-insurance or late cancellation. We will always provide a Fair Estimate of the cost of your treatment.

Client Forms

Becoming a New Client and Completing Forms

All of our CLINICAL and ADMINISTRATIVE forms can now be completed via secure direct electronic submission.

Insurance Information

**All of our CLINICAL and ADMINISTRATIVE forms can now be completed via secure direct electronic submission.**