Mind Balance Mental Health and Wellness, PLLC offers a credit card on file program as a convenient method of paying for the portion of your services that are the patient's responsibility such as copay, deductible, and co-insurance. Your credit card information will be kept confidential and secure.

I, {cardholderName}, as a cardholder,

authorize and request that Mind Balance Mental Health and Wellness charge my credit card for the balance due that my health plan has identified as my financial responsibility. This authorization relates to all charges not covered by my insurance company for services provided to me by Mind Balance Mental Health and Wellness. My card will remain securely stored for future use by Square, a secure credit card processor that partners with Mind Balance Mental Health and Wellness to collect payments. This authorization will remain in effect until revoked by me in writing.

By signing below, I authorize Mind Balance Mental Health and Wellness to keep my signature and my credit card information securely on file in my account. I authorize Mind Balance Mental Health and Wellness to charge my credit card for any outstanding balance when due. 

I have been informed that I can cancel the recurring payment at least 15 days before the payment by phone or signing a consent form provided by the merchant company.