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Home
Who We Are
Providers
Credentials
What We Do
Forms/Portal
New Patients
Referrals
Credit Card On File
FAQs
General Information
Medication Management
Testing Services
Resources
Blog
Suggested Reading
Crisis Resources
Contact Us
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Credit Card on File
Consent Form
Credit Card on File
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*
" indicates required fields
Patient name:
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First
Last
Date of Birth:
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Month
Day
Year
Card holder name:
*
First
Last
Last Four (4) Digits of Card Number:
*
Consent
*
I agree to have my card on file.
My Signature below indicates that, as the cardholder, I agree to authorize payment for services rendered by the service provider. By signing I agree to accept total responsibility of the bill, in which total amounts may reflect 1. The full amount owed for service, 2. Copayment of insurance benefits, 3. Payment of any applicable missed appointment fees, or 4. Other payment arrangements agreed upon by the patient, cardholder, and/or service provider.
Patient/Custodial Parent/Guardian Signature:
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Today's Date:
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