MA Credit Card Authorization Form

MA Credit Card Payment Authorization Form
Please complete all fields below. You may cancel this authorization at any time by contacting Northeast Family Services. This authorization will remain in effect for one year from the date of signature.

Please complete the information below:
NFS Client Name:*

First NameLast Name
NFS Program for Services:*

IHBSIHTOPSUD
Name of NFS Clinician or Paraprofessional:*

First NameLast Name
Cardholder Name:*

First NameLast Name
Phone Number:*

Area CodePhone Number
Email:
example@example.com
Account Type:*

VisaMasterCardAMEXDiscover
I authorize Northeast Family Services to charge my credit card account indicated below for charges associated with therapy appointments. I understand my information will be kept on file for future transactions for one year.
I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Signature:*

Clear
Date:*

MonthDayYear
Date

Co-Payment Amount*

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

MA Credit Card Payment Authorization Form