Electronic Payment Authorization Form printable pdf download

ELECTRONIC PAYMENT AUTHORIZATION

Please indicate the card you wish to use for all services rendered through this practice. Charges for services

rendered will be deducted from the card designated below at the time services are rendered. We accept: Visa, MC

and Discover.

Client Information:

Client Name: __________________________________________________ Date of Birth: ______________________________

Address: _______________________________ City___________________________ State: ____________ Zip: _____________

Home Number: ______________________ Mobile Number: ____________________ SSN:___________________________

Email: _______________________________________________________________________________________________________

Billing Information:

Please indicate the information associated with the debit card you wish to use.

I prefer to use a credit card.

Name: _____________________________________________________________________________________________________

Address: _______________________________ City___________________________ State: ____________ Zip: ____________

Email: ______________________________________________________________________________________________________

I authorize all service fees to be deducted from the card ending in _________________ (last four digits of the card)

Please enter the CVV code ______________ (last three digits on back of card)

I authorize the use of this card for all services and fees at the time they are rendered for the following parties:

Full Name(s) ________________________________________________________________________________________________

I understand that this form authorizes my provider to charge this card for varying session types, across multiple

dates of service. *By authorizing use of this card, and signing this electronic payment authorization form, I certify

that I am the cardholder and my signature below authorizes each individual charge for all dates of service.

___________________________________________________

_______________________________

Cardholder Signature

Date

Payments are processed by Therapy Partner.

Therapy Partner is a registered ISO/MSP of Fifth Third Bank, Cincinnati, OH and HSBC Bank USA National Association, Buffalo, NY.

I prefer to use a credit card.

Debit Card Information:

Please provide your payment information below. The card information you provide on this form will be destroyed

once your information has been securely encrypted and stored.

Card (circle one):

Visa

MasterCard

Discover

Card Number: ____________________________________________________________ Expiration Date: _______________________

Electronic Payment Authorization Form