Payment Authorization Form for Therapy Clients at Barnum Counseling

PAYMENT AUTHORIZATION FORM

We require a credit card on file for the following reasons: payment for services including self-pay rates, copays, deductible amounts; also for missed appointments, late cancel fees, or any other fee that is deemed patient responsibility.

Please note: payment is due at the time of the session. Your card will be charged after each session for the fee (copay, deductible, self-pay amount) related to services received or other out-of-pocket expense per your agreement with Barnum Counseling. Outside of these charges, your card will ONLY be charged in the event of an outstanding balance deemed patient responsibility by insurance or by the fee agreement that you have signed with Barnum Counseling.

Thank you.

THIS INFORMATION MUST BE COMPLETED. ALL INFORMATION IS KEPT CONFIDENTIAL AND WILL ONLY BE USED AS INDICATED ABOVE.

Credit Card Number :

Expiration Date:

V-Code (3 digits):

Name as it appears in card:

WANT TO USE YOUR HAS/FSA CARD?

Credit Card Number:

Expiration Date:

V-Code (3 digits) :

Name as it appears in card:

Please note: if you are using a FSA/HSA card, you are required to fill out BOTH sec􀆟ons above. Your FSA/HSA will be charged first for services rendered, and the credit card will only be charged in the event that your FSA/HSA card is out of funds, or for other out of pocket expenses, as indicated in your client contract.

I authorize Barnum Counseling, which includes my provider and/or the administrative team, to electronically debit or charge my credit card for payment for services, out-of-pocket expenses, or any outstanding balance owed per our agreement. I agree that no prior notification may be provided for these charges and that I do not have to be present for this transaction/these transactions to occur.

Client or other authorized party signature:

Date: