Credit Card Update Form

New Patient Information

Today's Date
MM slash DD slash YYYY
Credit Card Authorization*
I agree to pre-authorized credit card billing.
We require credit card information to be on file as a guarantee against unpaid balances. You may also use your credit card on file for recurring co-pays. By presenting the credit card information you authorize psychological associates to charge your account for any balance is not paid for by insurance and for any late cancellations or missed appointments.
Note regarding credit card information: When you provide credit card information online your information is entered into Square credit card processing service. All of your information is stored on the secure Square site. No information is kept in our office.
Patient Name
Name as on Card*
Zip code associated with the card*
Account #*
Expiration Date*
Security Code*
Consent to fee agreement and office policies*
I agree to the terms of the fee agreement and office policies
I have read the above the agreement, have asked any questions that I may have, and agree to the terms described above. I have reviewed a copy of the HIPPA privacy notice and a copy of office policy and procedures. I consent to receive services from Psychological Associates (If a parent, I consent for my minor child to receive services. )