Credit Card Authorization Form I allow Psychology Associates of Grand Rapids to electronically store my credit card information on file (choose one):Please use my stored credit card information to (Please choose ONE)* pay my balance in full on 5th/20th/both (choose below) process a monthly payment on my outstanding balance pay my copay or deductible at my time of service If you chose to pay a monthly payment, specify the amount to be charged per month until your balance is paid in full: I would like my payment to be processed on the (Please choose ONE)* 5th day of the month 20th day of the month both days at my time of service Do you need to receive an emailed receipt after each transaction? (Please choose ONE)* I do need to receive an emailed receipt. I do not need to receive an emailed receipt. Email address Patient Name* Date of Birth* MM slash DD slash YYYY Cardholder Name* Check here to electronically sign this document* I agree to authorize my credit card to be used as above. Today's Date* MM slash DD slash YYYY The credit card numbers listed below will be stored electronically in our billing system. Once they are entered this form will be deleted.Credit Card Number* Expiration Date (MM/YY)* CVV* Doctor/Therapist's Name* Untitled
