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Credit Card Authorization

Credit Card Authorization

  • , HEREBY AUTHORIZE CAPITAL MENTAL HEALTH TO KEEP THIS FORM AND MY SIGNATURE ON FILE AND CHARGE MY CREDIT CARD ACCOUNT FOR ANY OF THE FOLLOWING:
        1 INITIAL EVALUATION
        2 PSYCHOTHERAPY SESSIONS, MEDICATION SESSIONS, AND OTHER RELATED SERVICES
        3 APPOINTMENTS WHERE I DO NOT NOTIFY CMH OF A CANCELLATION WITHIN 24 HOURS OF THE SCHEDULED APPOINTMENT
        4 ADDITIONAL AND/OR FUTURE SERVICES THAT I APPROVE VERBALLY; AND/OR
        5 PAYMENTS THAT ARE 30 DAYS PAST DUE
  • (LAST 3 DIGIT NUMBER LOCATED ON THE BACK OF CARD ON OR ABOVE SIGNATURE LINE)
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.