Co-Pays/Co-Insurance/Self-Pay: Payment is due at the time services are rendered.Outstanding Balance: If your insurance provider has paid their portion of your bill and there is still an outstanding balance owed, Small Talk Pediatric Therapy will charge the card on file. A receipt will be emailed to you after the payment has posted to the patient(s) account.I, (type name) First Name* Last Name*, authorize Small Talk Speech & Language Services LLC, dba Small Talk Pediatric Therapy to charge my credit card above for agreed upon purchases as of (Date) Date* . I understand that my informationwill be saved to file for future transactions on my account. This authorization will remain in effect until termination of services and settlement of final balance. In providing us with your credit cardinformation, you are giving Small Talk Pediatric Therapy permission to automatically charge your credit card on file for (the patient(s) you have listed on this form) self-pay sessions, co-pays or co-insurance, late cancellation fees, no-show fees, and/or outstanding balances.