Payment Plan Authorization Form

I, (card holder) authorize Beyond Mental Health to charge the agreed amount of to my credit card provided herein on the day of each month for a total of payments on behalf of (patient name).


Credit Card Information

Name on Card :

Billing Address:

City: State: Zip:

CC Number:

Exp. Date: CVV (3 or 4 digits on back):

Printed Name of Card holder: Date:

Leave this empty:

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Signature Certificate
Document name: Payment Plan Authorization Form
lock iconUnique Document ID: 59ef9711cda3a0675635d85bf8b80521fc6aae73
Timestamp Audit
January 24, 2024 5:16 pm CDTPayment Plan Authorization Form Uploaded by BMH Front Desk - IP
June 18, 2024 3:34 pm CDTBMH Billing - added by BMH Front Desk - as a CC'd Recipient Ip: