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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).

Email:

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:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

January 24, 2024 5:16 pm CDT

Payment Plan Authorization Form Uploaded by BMH Front Desk - frontdesk@beyond-mh.com IP 173.175.118.194