Credit Card Authorization Form

We REQUIRE a credit/debit card to hold your scheduled therapy appointments, regardless of billing and even if you are using cash to pay for your sessions.

We will bill your credit card for:

Fees for your therapist if not using insurance
Estimated cost shares as indicated by your medical plan (co-pays, coinsurance, deductibles) at time of appointment
Remaining balance of cost shares upon receipt of explanation of benefits (if an overpayment was made, a credit will be applied toward future appointments if you are still in treatment or a refund issued if you have discontinued
therapy)
Cancellation fees for missed appointments or less than a 24-hour cancellation of your scheduled appointment,
Indirect and secondary services (see Informed Consent for description)

Client Name *

First Name Last Name

Date of Birth *

Date

Name EXACTLY as it appears on your credit card:

Cardholder Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Your Billing Information *

Dummy Product

$ 0.01

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Email

example@example.com

I authorize The Resilience Group to keep my signature and credit card number on file, and to charge my credit card account for the purposes of:

Fees for my therapist if not using insurance
Estimated cost shares as indicated by my medical plan (co-pays, coinsurance, deductibles) at time of appointment
Remaining balance of cost shares upon receipt of explanation of benefits (if an overpayment was made, a credit will be applied toward future
appointments if I am still in treatment or a refund issued if I have discontinued therapy)
Cancellation fees for missed appointments or less than a 24-hour cancellation of my scheduled appointment,
Indirect and secondary services (see Informed Consent for description)

I understand this form is in effect unless I cancel the authorization in writing or three (3) years from date of signature. I will not dispute the charges for reasons outlined above. I further authorize The Resilience Group to disclose my protected health information (PHI) to their credit card processing company and my credit/debit card issuer if I dispute a charge.

Signature *

Clear