Credit Card Authorization Form To streamline billing and reduce missed payments, you have the option of keeping a credit or debit card securely on file. Your card will be charged for any amount not covered by your insurance or for any late cancellation/no-show fees, as outlined in our policy, in the manner you choose below. We use a HIPAA-compliant, encrypted system to store your information securely. You may update your payment method at any time.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 the last business day of the month. pay my copay, deductible, and/or late cancel/no-show fee at the 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 addressPatient Name*Date of Birth* MM slash DD slash YYYY Cardholder Name*Cardholder Zip Code*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 in our HIPAA-compliant encrypted system. Once they are entered the bottom portion of this form will be destroyed.Credit Card Number*Expiration Date (MM/YY)*CVV*PAGR Provider's Name*
