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:
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.