CC Processing Form

The Northampton Center for Couples Therapy

Credit Card Processing Form
The Northampton Center for Couples Therapy (NCCT) and its Billing Agency* are authorized to keep my signature on file and charge my account for any balances due from NCCT services rendered to me or my family not covered by my insurance plan. I understand that this authorization will remain in effect until NCCT has received written notification from me of it's termination in such time and manner to afford NCCT a reasonable opportunity to act on it.
Patient Name

First Name Last Name
Last 4 digits of CC
Please note that we will ask for your CC information in full during our intake call.
Signature

Clear
(If applicable) I am also authorizing NCCT and it's Biling Agency to use the above listed credit card for my spouse/partner for all balances on their account as well. I know that this is in addition to the balances on my account. My signature above authorizes NCCT to apply balances from my spouse/partner's account although my spouse/partner's name is not on the credit card being used at this time.
Spouse/Partner's Name

First Name Last Name
Spouse/Partner's Signature

Clear
*This authorization shall also apply to our billing agency that is covered under a confidentiality agreement with NCCT as well as a HIPAA Business Associates Agreement.

Please note that NCCT shall keep the above information confidential. NCCT shall use all reasonable efforts to preserve the secrecy and confidentiality of the above information. NCCT shall not disclose such confidential information to any third party outside of NCCT's practice.

Effective 10/1/2012 Signature of NCCT Credit Card Processing Form is required of all NCCT clients.
Should be Empty:

The Northampton Center for Couples Therapy