MBC Credit Card Authorization Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please fill out this secure form as the Credit Card that you have on file has expired or is no longer valid.

Email *

Patient Name *

Please read the follow statements and check all boxes to confirm your understanding of Mind Body Co-op's credit card policy *

By checking this box, I authorize my therapist at Mind Body Co-op (MBC) to charge my credit/debit/health savings account card for professional services at the time of service. This charge includes any insurance deductible, co-pay, co-insurance and any charges that are not covered by my insurance plan.

By checking this box, I understand that MBC has a 24-hour cancellation policy for all individual sessions. This means that I must give my clinician at least a 24 hour notice to cancel my session without a $100.00 cancellation fee. I understand that if I do not give 24-hour notice to cancel my appointment, or if I do not attend my appointment, I will be charged a $100.00 fee.

By checking this box, I understand that all group therapy sessions at MBC require a commitment of weekly attendance. I understand that I will be charged a $30 fee if I do or do not give a 24-hour notice.

By checking this box, I understand that the billing department at MBC will work diligently to dispute any denied claims and advocate for insurance coverage. I agree to provide the necessary information to the billing department in order to resolve any insurance denials.

By checking this box, I verify that my credit card information, provided in the Bill to and Insurance Information of this client portal, is accurate to the best of my knowledge. If my credit card expires, my clinician will inform me and I will replace the card on file at MBC.

By checking this box, I understand that if the credit card information is incorrect or fraudulent or if my payment is declined, I understand that I am responsible for the entire amount owed and any interest or additional costs incurred if denied.

By checking this box, I understand by that if no payment has been made by me, my balance will go to collections if another alternative payment is not made within thirty days.

By checking this box I agree that no prior notification of credit card charges are necessary unless the amount billed each time exceeds $250.00.

Required

Credit Card Number *

Expiration Date (mm/yy) *

CVV Code on the back of the Card *

billing zip code *

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Mind Body Co-op. Report Abuse

Forms