Payment Agreement

Patient/Parent Permission to Auto-Charge Debit or Credit Card on File
Please read below and sign to confirm your agreement regarding your current card card information that we have on file at the Speech Language and Learning Center of TN, LLC.
This card is used to pay for speech & OT services for: (patient's name)
The information from this card may be kept in a secure location within the Speech Language and Learning Center of TN's billing and record keeping secure computer files.

This Card may be automatically charged each time a visit is completed. I understand that the following rates for services apply and will be charged for speech and/or occupational:

Should rates change, I will be notified by the SLLC of TN before the card is charged.
Address for cardholder:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Name:

First NameLast Name
Cardholder's Signature:
Cardholder's Printed Name:

First NameLast Name
Date:

MonthDayYear
Date
Card Number:
Expiration Date on Card:
CVV:
Should be Empty:

Patient/Parent Permission to Auto-Charge Debit or Credit Card on File