Debit/Credit Authorization Form

Debit/Credit Authorization Form

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We value our relationship with our clients. As part of keeping your trust, we want to make sure that we are charging your card on file as you authorize, and protecting your card information in a secure system. Please bear with us-- we want to make absolutely sure that we are doing everything to protect your private financial information. This involves a 2-step process: 1) This authorization form, so you can specficy in detail what, how much, and when, to charge your card on file, and 2) Entering your card information on your online account with us. Once the card is stored in our system, the card information is stored securely so that no one can see the specific card information, but we will be able to charge your card as you tell us.

You may use your debit or credit card, as well as a HSA or FSA (health benefits) payment card.

To set up a debit/credit/HSA/FSA card on our system:

1) Complete this Debit/Credit Authorization form. On this form, you specify when and how much we are authorized to charge to your card.

2) Get your card information into your online account with us:

Login in to your Online Account.
Click on "My account" at the top of the screen
Click on "Credit Cards on File" on the left side.
Click on "Add New Card" at the top of the screen.
NOTE: Are you paying for more than one person? You may make a note of which client's you are paying for in this form, but we will need you to enter this card information on each person's online account at ccnps.janeapp.com.
If for some reason, you are unable to get into your online account with us, contact your clinician for assistance.

You may cancel your authorization at any time and ask that your card be removed from our system. Just let your clinician know, or use the send us a message link on our website.

A new card on file.Update a card on file.Replace a card on file. Please delete the old one.Remove a card on file

Cardholder Information:

IMPORTANT: This form must be completed and signed by the card holder who authorizes the charges.
This authorization is for the credit/debit card on file with CCNPS, which has the last 4 digits of: *
Please remove the credit/debit card on file that has the last 4 digits of: *
Note: This authorization will be used ONLY for the card with the last 4 digits listed here.,
VISAMastercardDiscoverAmerican Express
Cardholder Name, as listed on the debit/credit form*

Cardholder First NameCardholder Last Name
Cardholder Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cardholder Phone:*
In case we have questionsFormat: (000) 000-0000.
Client Information:
Which clinician is being seen? *
I am the client and cardholder authorizing payment.
Client Name:*

Client 1 First NameClient 1 Last Name
I wish to authorize charges to my card to pay on another client's account.
Which clinician is being seen? *
Client Name:*

Client 1 First NameClient 1 Last Name
I wish to authorize charges to my card to pay on another client's account.
Which clinician is being seen? *
Client Name:*

Client 1 First NameClient 1 Last Name
GENERAL AUTHORIZATIONS AND PERMISSIONS:
I understand that this form authorized the use of my stored credit card.
If I do not provide an accepted alternative form of payment at the time of the charge, I preauthorize Counseling Centers of North Puget Sound (CCNPS) to charge my credit/debit card on file, for any and all: Late fees, missed appointment or late cancellation fees, clinical records fees, when policy coverage has been exhausted, and any outstanding, past-due balances.
I understand that I must provide notice in writing to terminate this permission.

SPECIFIC AUTHORIZATIONS (NOTE: If you leave the $ amount blank, you are authorizing us to charge your card on file up to the full amount due at the time the card is charged):

Rows	Click to authorize:	$ Amount :
Copayments: Charge my card for all copayments as determined by my healthplan at the time of service, or at the end of the month for all sessions that month up to this amount (per session):
Client Responsibility: Charge my card for any amount that is my responsibility after insurance claims have been processed (deductible amount, copayments, co-insurance, or denied claims), at the time the claim is received, or at the end of the month, up to this amount:
Charge my card, at the time of service this amount:
Charge my card, at the end of the month, up to this amount:

Additional Instructions:
Enter names of additional clients you are authorizing payments for, or any other instructions you wish us to have.

Terms and Conditions:

I certify that:

1) I am the cardholder listed above,
2) The information for the credit card and billing address is complete and accurate.
3) I have been informed that I can cancel the recurring payment at least 15 days before the payment by phone, by secure messaging, or by signing a new consent form.

I preauthorize Counseling Centers of North Puget Sound (CCNPS) to:

1) Charge the debit/credit card listed in this form as indicated above.
2) If I entered a specific amount in the Specific Authorizations above, then I authorize CCNPS to charge the amount due, up to that amount specified.
3) If I didn't enter a specific amount for the authorization above, I am authorizing CCNPS to charge the full balance due from the client at the time of the charge. (this does not include any health insurance claims that have yet to be processed).

I understand and agree that CCNPS is not responsible for any errors made on this form.

Date*

MonthDayYear
Date
Cardholder Name:*

First NameLast Name
Signature of Cardholder:*

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Debit/Credit Authorization Form

Cardholder Information:

Client Information:

GENERAL AUTHORIZATIONS AND PERMISSIONS: