Credit Card Authorization Form

Credit Card Authorization Form

This information is private and confidential
All patients are required to have an active credit card on file, even if you are using insurance, in the event of last minute cancellation or no-shows. Payment is due at the time of service, or at the session following a "no show", defined as a cancellation with less than 48 hours notice. If you prefer to pay by cash or check, please do so at the time of service, or at the session following a "no show." If payment is not received at the time of service or at the next session following a "no show," we will wait fourteen (14) days for a check to be received by mail. After 14 days your credit card will be charged for any balance due.
Please advise us immediately if your card is lost or stolen
I hereby authorize this credit card to be used for payments for services rendered by Bhava Therapy Group. This authorization will remain in effect until the expiration date of the card or a written request to revoke the authorization is sent to us at 3580 Netherland Ave, Ground Floor, Bronx NY 10463 or 280 Madison Ave, Suite 210, New York NY 10016.
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Therapy Sessions, Cancelation and No Show Fee's Free
Therapy sessions (at a maximum of) $170 or as determined by Bhava Therapy Group or your insurance company.
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Please click one of the PayPal options to complete payment and submit the form.