🔒 Halidom Psychiatric Health & Wellness

Consumer Disclosure for Electronic Signature and Credit Card Authorization

This Consumer Disclosure applies to the use of electronic records and electronic signatures in connection with the Credit Card on File (CCOF) policy and authorization agreement at Halidom Psychiatric Health & Wellness.

By accessing and signing the Credit Card Authorization Form electronically, you consent to the use of electronic records and signatures in place of paper documents and handwritten signatures. This disclosure informs you of your rights when electronically signing documents with our practice.

What You Agree To

By electronically signing the CCOF Authorization Form:

  • You affirm that you have read, understood, and agree to the terms of the Credit Card on File Policy.

  • You authorize Halidom Psychiatric Health & Wellness to store your credit or debit card securely on file.

  • You allow us to charge the card in accordance with your insurance benefits and any outstanding balance you may owe following claim processing.

  • You understand that your card will be charged after insurance processes your claim and you are notified of your remaining balance (if applicable), within a five (5) day window before your card is charged.

  • You confirm that you have access to the hardware and software required to view, save, and print these documents for your records.

Security and Storage

Halidom Psychiatric Health & Wellness uses a HIPAA-compliant, PCI-DSS certified payment processor embedded within our electronic health record system to store and process credit card information. Your full card number is never visible to our staff and cannot be exported or used outside of the secure billing environment.

Only the last four digits of your card number are stored in our records for reference.

Revocation of Authorization

You may revoke your credit card authorization at any time by submitting a written request to Halidom Psychiatric Health & Wellness. Revocation of authorization does not apply to charges that have already been processed or are in progress at the time of revocation.

Should you wish to update or replace your card, you may do so securely through our patient portal or by contacting our office.

Paper Copies

You have the right to request a paper copy of the CCOF Policy, Authorization Form, or this Consumer Disclosure at any time, free of charge. To request one, please email us at help@halidomwellness.com or call our office.