Psychology and Counseling Associates

Credit Card on File

"*" indicates required fields

Patient name:*

First Last

Date of Birth:*

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:*

Today's Date:*