PSYCH ATLANTA
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.