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:

Credit Card Information









Leave this empty:

Signature arrow sign here


Signature Certificate
Document name: Credit Card Payment Authorization Form
lock iconUnique Document ID: 37d5c585f688ce463aec3613c622124a608d7df6
Timestamp Audit
June 18, 2022 9:32 am CDTCredit Card Payment Authorization Form Uploaded by BMH Front Desk - frontdesk@beyond-mh.com IP 66.68.60.75