Credit Card Payment Authorization Form
To simplify the process of payment of copays and other charges, we ask to have a credit card on file. Please indicate credit card information below and sign where indicated.
Note: if receiving talk therapy at Beyond Mental Health, by signing below, you indicate consent to a policy making a credit card mandatory for talk therapy copayments.
I, , as the individual card holder and/or patient, hereby authorize this card to be used for:
Name on Card: CC Number: Exp. Date: CVV (3 or 4 digits on back): Billing Address: City: State: Zip: Printed Name of Card Holder:
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Credit Card Payment Authorization Form
Agree & Sign