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: c19769438069252a6b5c801820941edcb3b41c03
Timestamp Audit
June 18, 2022 9:32 am CSTCredit Card Payment Authorization Form Uploaded by BMH Front Desk - frontdesk@beyond-mh.com IP 173.175.118.194
June 18, 2024 3:33 pm CSTBMH Billing - billing@beyond-mh.com added by BMH Front Desk - frontdesk@beyond-mh.com as a CC'd Recipient Ip: 173.175.118.194