As a service to our patients Heather Hirsch MD, PLLC has the ability to securely store your credit card(s) in our system. By signing this form, you give permission to Heather Hirsch MD, PLLC to charge your credit card for services rendered.
AGREEMENT
I understand an annual membership minimum of 1 year allows our clinicians to create a shared decision plan with our patients, ensuring an integrative approach to excellence in midlife care.
The Collaborative Membership is a 12-month commitment, with allowance for monthly payments for your convenience.
- No Refunds: Membership fees are non-refundable, including for unused benefits or partial months.
- Early Cancellation: Canceling early does not waive the remaining payments for the year.
- Missed Payments: We’ll send a reminder if a payment is missed. If multiple payments go unresolved, the remaining balance for the year will still be due per the agreement.
I authorize Heather Hirsch MD, PLLC to store my credit card information and bill the credit card on file for services I receive. I understand that Heather Hirsch MD, PLLC will only charge this credit card for amounts authorized by me, and that upon request, a receipt will be provided for all charges processed. I will notify Heather Hirsch MD, PLLC in writing if I no longer want my credit card information billed or automatically billed. I further understand that any purchases prior to revoking this agreement still may be charged to this card unless an alternate form of payment is provided.
I acknowledge that no hospital or health care provider is permitted to require credit card pre- authorization prior to providing emergency or medically necessary medical services to me. I further acknowledge that by using a credit card to pay for medical services, I am foregoing any state and federal protections regarding medical debt—unless the card used is a “medical credit card” (a credit card issued under an open-end or closed-end plan offered specifically for the payment of health care services, products, or devices provided to a person).