Credit Card Authorization Form

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An additional authorization form should the cost of services be covered by someone other than the client. All packets include this form, this is an additional one to be used as needed.

Client's Name *

Cardholder Name: *

Credit Card Number *

Expiration Date *

YYYY

Security Code (on the back) *

Billing Address (including city, state, zip) *

Authorization

I, the undersigned, authorize and request A New Hope Therapy Center to charge my credit card, indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibility. I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my credit card company; so long as the transactions correspond to the terms indicated in this authorization form.

This authorization relates to all payments not covered by my insurance company for services provided to me by A New Hope Therapy Center.

This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 60-day notification to A New Hope Therapy Center in writing and the account must be in good standing. This information will be destroyed when account is closed. Any disputes need to be in writing no later than 90 days of last date of service.

Typing your full name indicates consent and agreement: *

Today's Date: *

YYYY

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