ELECTRONIC PAYMENT AUTHORIZATION

Please complete the following information. Session fees for all clinical treatment will be deducted from the account designated on this form. Forms of payment accepted: Visa, MasterCard, Discover, and E-Checks. This form will be securely stored in your clinical file and may be updated upon request at any time.

CLIENT INFORMATION:

Client Name:________________________________ DOB:___________________ Social Security Number (Responsible Party): _____________________

Responsible Billing Party Name (as shown on Credit Card/Account):______________________________________________________________________

Billing Address (as registered with Credit Card Company/Bank): ______________________________________________________City_______________

State______ Zipcode_______________ Mobile Number:_____________________ Home Phone Number:___________________

Email:_________________________________________________________________

FORM OF PAYMENT: Check One: Credit/Debit Card: _______ E-Check: _______

ACCOUNT INFORMATION: Card Type (Visa, MasterCard, or Discover):_____________ Card#:___________________________________________

Expiration Date:_________________ Three Digit Card Code (Located on Back of Card): _________

Or Bank Name:_______________________________ Checking Account#:_______________________

Routing#:_______________________

Client Signature________________________________________________ Date__________________

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