Self-Pay Program Agreement Form - PursueCare

PursueCare Self-Pay Program Agreement Form

Please read below then sign at the bottom.

  • The following is a financial agreement between you and PursueCare, LLC that states your rights and financial responsibility as a self-pay patient.




  • The self-pay program exists to provide affordable services to those in need. Patients will work with healthcare professionals to determine a treatment plan and frequency of sessions and other services. Payments made as part of this agreement will cover the expenses for the services listed under the bundle that is selected. Additional services are priced separately and detailed within each bundle option.

  • To qualify for the self-pay program, an active form of payment must be on file throughout the duration of the program subscription. Payment information is kept securely by PursueCare in accordance with federal and state regulations. By signing this agreement, you authorize PursueCare to charge the card on file an initial deposit amount of $50 within 7 days of signing this agreement. The remaining amount for the first month will be charged within 7 days of your first session. You also authorize PursueCare to process charges on a recurring basis for the selected bundle and an additional fee for each additional service rendered.

    The credit card on file will be used to process recurring payments. If a payment is declined or does not process for any reason, PursueCare will attempt to contact patient to update the information. If the payment is not processed timely, services may be cancelled at the discretion of PursueCare staff.

    Cancellation of services:

    PursueCare reserves the right to cancel this program for non-payment. No shows do not result in a refund or cancellation of the subscription.

    The patient can cancel by contacting the Care Coordination or Intake staff. Cancellation must take place at least 48 hours before the next payment is scheduled to process. Recurring payments will continue until cancelled by the patient or PursueCare staff.

    Refund Policy:

    Payments cannot be refunded once processed. The patient can cancel services and stop any upcoming payments from processing, but this must be done within 48 hours of the process date.

    By my signing below, I acknowledge that I have read and understand the above and have been given the opportunity to ask questions. I understand that I am completely responsible for all costs associated for all services provided to me. I confirm that I am the patient, or the patient’s duly authorized representative.

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

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