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

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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 - IP