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 a monthly statement? (Please choose ONE)* I do need to receive a monthly statement. I do not need to receive a monthly statement. 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*
