Credit Card Authorization

I,*
, 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:
NAME(AS IT APPEARS ON THE CREDIT CARD)*
First
*
- VISA
- MASTERCARD
- AMERICAN EXPRESS
- DISCOVER
CREDIT CARD NUMBER*
EXPIRATION DATE*
CARD CODE:*

(LAST 3 DIGIT NUMBER LOCATED ON THE BACK OF CARD ON OR ABOVE SIGNATURE LINE)
CREDIT CARD BILLING ADDRESS*
Street Address City State / Province / Region ZIP / Postal Code Country
TELEPHONE*
*
- I UNDERSTAND THE TERMS OF THIS FORM AND AGREE THAT IT IS VALID FOR FIVE (5) YEARS UNLESS TREATMENT IS TERMINATED OR I CANCEL THIS AUTHORIZATION THROUGH WRITTEN NOTICE TO CAPITAL MENTAL HEALTH
CARDHOLDER SIGNATURE*
PRINTED NAME*
DATE SIGNED*
MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.