VENMO

Arrowleaf Payment Options

Do you need to pay your Arrowleaf Invoice?

It’s easy! Here’s how:

Pay by Cash, Money Order, or Check

Cash or check payments are preferred. Please do not send cash payments in the mail. If paying by cash, please visit us in person to submit your payment.

If paying by Money Order or Check, please mail your payment to:

Arrowleaf
PO Box 1328
Vienna, Illinois 62995

If you have any questions about your invoice or payment options, please call 618-658-3079.

No one will be denied access to services due to an inability to pay. There is a discounted/sliding fee schedule available based on family size and income. To inquire, please call 618-658-3079 or email info@myarrowleaf.org.

Pay with Venmo by searching @myarrowleaf under “Charities” or by scanning the QR code to the left.

Pay Online with Credit Card or Stripe

If you would like to submit an online payment via Credit Card or Stripe, please complete and submit the form below. After submitting the form, you will be taken to Stripe to complete the payment process. (NOTE: You do not need a Stripe account to pay your invoice by submitting the form below.)

Arrowleaf Online Payment Form

"*" indicates required fields

I am (please check one):*

An Arrowleaf Client

Submitting Form for a Client

Type of Payment (please check one):*

Payment on Account

DUI

Risk Education

Copies of Records

Toxicology Screen

Rent

Other

Client Name*

First Last

Client Phone*

Statement Date*

Client Account Number:

Email Address Instructions

If you DO NOT have an email account, we highly recommend that you set one up before submitting this application. You can set up a personal email account for FREE at these suggested sites: https://www.yahoo.com or https://www.google.com.

CLIENT EMAIL — By submitting my email address, I agree that Arrowleaf may communicate with me via email concerning my invoice and/or payment.

Enter Email Confirm Email

Contact Name (Person Submitting the Form for Client)

First Last

Contact Phone

CONTACT EMAIL — By submitting my email address, I agree that Arrowleaf may communicate with me via email concerning the Client's invoice and/or payment.

Enter Email Confirm Email

PAYMENT AMOUNT (Please indicate the amount you wish to pay below):*

Note: After completing this form and clicking the "SUBMIT PAYMENT" button, you will be taken to STRIPE to complete your payment transaction. Upon successful completion of the payment process, you will receive a receipt via email from your Credit Card Company and/or STRIPE with transaction details and confirmation of payment.

Comments/Special Instructions:

2 + 3 = (Help us prevent automated spam form submissions. Please enter the sum in the space below)*

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

No Surprises Act and Good Faith Estimates

The “No Surprises Act” helps ensure that uninsured consumers or consumers with commercial health insurance (health plans provided by an employer or purchased on the Health Insurance Marketplace) do not receive surprise bills for services provided to you at our agency.

If you are uninsured, underinsured, or don’t plan to submit your claim to your health plan, we must provide you with a “good faith estimate” of expected charges. The good faith estimate is NOT a bill.

Arrowleaf must give you a good faith estimate when you schedule an appointment at least three days in advance, or at any time during your treatment if you ask for one.

The estimate will include an itemized list and expected charges for services related to your care. The estimate will be provided in writing or mailed to you if you schedule over the phone.

All clients will be assessed a sliding scale fee during intake for a reduced amount based on household size and income. Additional fee reductions can be applied upon request.

If you get a bill for $400 or more above the good faith estimate, please contact us at 618.652.2047 for a review and dispute of charges.

For more information about the No Surprises Act and Goof Faith Estimates visit www.cms.gov/nosurprises or call 1.800.985.3059.

*Arrowleaf will not deny services due to inability to pay*