Credit Card Authorization/ Billing Form
Please complete this form if prompted by our staff at IBC.
Client's full name
*
First Name
Last Name
Client's DOB
*
-
Month
-
Day
Year
Date
Client's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Name of CARDHOLDER
*
First Name
Last Name
Card Type
*
Please Select
Visa
Mastercard
Discover
American Express
HSA
Expiration Date
*
Card number
*
Security Code
*
I authorize IBC to automatically bill the credit card I provided for my co-payment / co-insurance and/or deductible responsibilities, any out-of-pocket payments, and/or denials not covered by my insurance. I understand that I am responsible for the patient portions outlined by my insurance provider.
*
I agree
I authorize IBC to bill this credit card for any missed session fees incurred per our office's missed session policy.
*
I agree
I am an authorized user of the credit card and I will not dispute the payment with the credit card company so long as the transaction meets the terms of this authorization.
*
I agree
I acknowledge that all client payments are due at the time of session
*
I agree
Signature of CARDHOLDER
*
Print
Submit
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