Credit Card Authorization Form printable pdf download

Selby Psychological Services, PLLC

6 State St., Suite 208

Bangor, ME 04401

REDIT

ARD

UTHORIZATION

ORM

I am pleased to accept Visa or MasterCard for your payment today. As an added convenience, you

may authorize me to charge your card automatically for copayments due at each appointment, as well

as any outstanding balance you may have. Please allow up to five (5) business days to process your

charge.

Patient Name (Please Print): __________________________________________________________



One Time Charge Authorization: The undersigned card member consents and permits Selby

Psychological Services, PLLC, as applicable, to charge to my Credit Card Account specified

below.

Amount to be charged to my Credit Card today:

$ ___________ . _______



Recurring Charge Authorization: The undersigned card member consents and permits Selby

Psychological Services, PLLC, as applicable, to charge to my Credit Card Account specified

below, the amounts due from me for services provided to me during the applicable billing

cycles. I release Selby Psychological Services, PLLC, as applicable, from any and all claims

arising from the use of this service. I understand and agree that Selby Psychological Services,

PLLC, as applicable, may continue to charge such amounts to my Credit Card Account until

receiving notification from me that I have withdrawn this consent and permission, at which

time Selby Psychological Services, PLLC, as applicable, shall cease charging any such

amounts to my Credit Card Account.

Credit Card Number ____________ – _____________ – _____________ – _____________

 Visa

 MasterCard

Expiration Date: ______ / ______

Month

Year

Name as it appears on the card ________________________________________________________

Credit Card billing address ___________________________________________________________

City _______________________________________ State _______ Zip Code ________________

Signature ___________________________________________________ Date ________________

Send receipt via e-mail  Yes  No

(Your credit card number will not appear on the receipt.)

E-mail address (please print clearly)____________________________________________________

Credit Card Authorization Form

Revised 07/09/2007

Credit Card Authorization Form