Recurring Credit Card Form

Doctor/Therapist Name*
First Last
Payment in full (if self pay or using my services as an out of network provider) or copays/deductibles (if I am an in network provider with your insurance company) is due at time of services. Your insurance will be billed on your behalf. Any uncovered services, including, but not limited to: copayments, coinsurance, or deductible for scheduled and kept appointments, sessions cancelled without 24-hour notice, telephone consultations over 10 minutes, reports prepared outside of appointments and records review. These fees will be billed to the credit card supplied below.
This agreement shall remain in existence as long as I am a patient of:*
or until I provide a written retraction of this agreement. Receipts of credit card charges will be available upon request.
Patient Name:*
First Last
Account # (For Office Use Only):
Date of First Appointment:*
Date Format: MM slash DD slash YYYY
Card #:*
Please include spaces in the number as shown on card. For example 1234-5678-9111-0000
Expiration Date:*
Date Format: MM slash DD slash YYYY
Is Your Card an American Express?*
- Yes
- No
Four numbers on front for American Express (if applicable)*
Three numbers on back of card:*
Card Holder Name:*
First Last
Card Holder Phone #:*
Card Holder Email:*
Billing Address:*
Street Address Address Line 2 City State ZIP Code
By signing below, I agree to allow my provider to keep my credit card on file. I hereby authorize my provider or designated staff to bill my credit card for services rendered.
Date:*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.