CREDIT CARD AUTHORIZATION FORM
Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.
CREDIT CARD INFORMATION:
FOR PAYMENT PLANS: I authorize Psych Atlanta to charge my credit card the amount listed below monthly around the 15th of the month until all balances are paid in full. I understand that my information will be saved for this purpose.
FOR CREDIT CARDS ON FILE: I authorize Psych Atlanta to charge my credit card for agreed upon purchases and services. I understand that my information will be saved in a secure format and will be used for future transactions and outstanding balances on my and/or the patient account.