Payment Authorization Form

Payment Type

CashCredit CardPaypal / VenmoCheck

Please input our agreed upon price per session (in USD):

Payee / Card Holder / Account Holder

First NameLast Name

Email

example@example.com

Phone Number

Area CodePhone Number

Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Credit Card Type:

VisaMastercardAmerican Express

I authorize the maintenance of valid credit card or other payment information to guarantee my chosen payment option*

Clients are responsible for submitting all claims to their insurance provider.

I understand that I am individually responsible for all incurred charges, even if I direct you to bill another person. If I direct charges to be billed to another person, I represent that I am authorized to give you such direction. If I have directed you to bill charges to another person who fails to make payment when due, I will promptly pay on demand. I understand that if I commit to joining a weekly: individual, group, or couple therapy, I am responsible for paying for services . I understand that all payments for services are to be made payable directly to Dr. Mehri Aboutalebi. In the event that I dispute a credit card charge without first trying to resolve my concern directly with Dr.Aboutalebi , I agree to reimburse $25 per disputed transaction to compensate this is for the costs incurred in trying to recover disputed funds. I understand there is a 24-hour cancellation policy and that I will be charged without providing 24 hours advance notice to cancel a session. I hereby authorize Dr.Aboutalebi to submit billing to my insurance company in relation to my treatment with her and further authorize that payment relating to this treatment is hereby assigned to Dr.Aboutalebi. I understand that disclosure of confidential information may be required by my health insurance in order to process the claims. I understand that only the minimum necessary information will be communicated to the carrier in order to process the claims.

Insurance Company (N/A if none):

I have read, understand and agree to the information, authorization and guarantee stated above.

First NameLast Name

Signature*

Date