Credit Card Acknowledgement

Credit Card Acknowledgement Form
Client Name*

First NameLast Name
Your Relationship to the Client*
Your Name

First NameLast Name
Email*
example@example.com
Date*

MonthDayYear
Date
Last 4 digits of the credit card on file*
Type of Card*
SLC requires a backup card on file if the primary card on the account is an HSA. Please fill out another Payment Authorization Acknowledgement form for your backup card, and contact our office to place the backup card on file. Additionally, please let us know if there is a certain day of the month that your HSA gets reloaded (if known).
By signing this form:
- I understand that Silver Linings Counseling has my credit card number on file, and requires all clients to have a form of payment on file.
- I understand that Silver Linings Counseling has stored the credit card number given to them in lieu of me signing their payment authorization form and filling out my information myself in their client portal.
- I understand that Silver Linings Counseling will charge any copays, account balances, and missed appointment fee to this card.
- I understand that payment is expected at the time of service and that Silver Linings Counseling will automatically charge my card for session fees, copays, or missed appointment fees. If appointments go towards my deductible, they will be charged as they process through insurance.
- I understand that an appointment is deemed "missed" if at least 24 hours advanced notice is not given to my therapist and/or the front office staff (with the exception of emergencies).
Signature

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Credit Card Acknowledgement Form