Credit Card on File Authorization

Credit Card on File Authorization

Thank you for choosing Vanda Counseling for your mental health needs. We are committed to providing you with exceptional care, as well as making our insurance billing processes as simple and efficient as possible. Recent shifts in the healthcare industry have resulted in insurance companies increasingly transferring costs to our clients, you, the insured. This is driving many practices to adopt new financial policies to enable more efficient operational processes. To streamline our billing and payment system and to provide a seamless, convenient way for you to pay your bill, as of 3/21/2022, Vanda Counseling will begin requiring all clients to keep an active debit or credit card on file. If you prefer to pay your bill with cash or check, you may make arrangements with your therapist to do that; however, we will still require a credit card on file for circumstances that require it. Circumstances when your card would be charged include but are not limited to: missed or canceled sessions without 24-hour notice, missed co-payments and/or co-insurance, and any non-covered services and/or denial of services. If you are unable to provide a credit card number, limited exceptions can be made at the discretion of Vanda Counseling. Please fill out the secure, encrypted credit card authorization form below.
Information to be completed by the card holder:
Card Type:*

VISAMaster CardAmerican ExpressDiscover CardOther
Billing Zip Code:*
Email:*
I Name*, authorize Vanda Counseling and Psychological Services to charge the above credit card account for payments owed to my account for services rendered at their office. I agree to update any information regarding this account. The above information is complete and correct to the best of my knowledge.
Name
Card Holder Signature:*

Clear
Date*

MonthDayYear
Date
Therapist Name*
Should be Empty:

Credit Card on File Authorization

Information to be completed by the card holder: