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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:

Future copays/sales tax for therapy appointments only

Future copays/sales tax for all treatments/appointments

Current balance and future copays/sales tax

Current or partial balance only:

Credit Card Information

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

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

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Timestamp

Audit

June 18, 2022 9:32 am CDT

Credit Card Payment Authorization Form Uploaded by BMH Front Desk - frontdesk@beyond-mh.com IP 66.68.60.75