Clinical Services of Rhode Island

I authorize American Addiction Centers, Inc. (AAC) to schedule and initiate the payment listed above for the account listed. You affirm that the information provided is accurate and that you are a signer on the account. You acknowledge there are no refunds for services rendered. You agree that any unused portion of amounts collected will be applied first to outstanding balances owed to AAC; any remaining amounts may be refunded upon request.

Customer Information

First Name:

Last Name:

Email Address:

Address Line 1:

Address Line 2:

City:

Zip:

Payment Information

Routing Number:

Account Number:

Usio, Inc. processes ACH transactions on behalf of Adcare of Rhode Island. By clicking ‘Submit’ below you agree to pay via this ACH Authorization. You acknowledge that you are voluntarily choosing to pay electronically. You understand and acknowledge that you may terminate the ACH Authorization by notifying us at support@usio.com, subject: ACH Authorization Disputes, and in such time and manner as to afford us and your bank a reasonable opportunity to act on it.

If the client leaves treatment early, either against medical advice or due to failure to follow facility policies, any discounted rates will be voided and the patient will be responsible for the full chargemaster rate per Provider, available upon request. Charges calculated at the chargemaster rate shall not exceed the originally agreed‑upon cost of treatment for the originally agreed‑upon period.