I hereby authorize Four Leaf Wellness to verify information required for processing payment, and to collect payment directly from my insurance. I also authorize Four Leaf Wellness to obtain any medical information on me as needed. I understand that if my insurance fails to cover my treatments, or pays me directly, I am responsible for making payments to Four Leaf Wellness. I agree to provide my credit card number today to be kept in a secured file with Four Leaf Wellness in the case that my insurance fails to cover my treatments. I understand that Four Leaf Wellness will contact me before charging my account, but if my insurance doesn’t pay for the services provided my credit card will be charged for the unpaid portion(s) of the service(s) rendered.

By submitting this form, I certify that all information I have provided is accurate to the best of my knowledge and that I agree to pay any and all portions of treatment(s) that are not covered by my insurance.