Original HPPGA - Credit Card Auth

Healing Psychotherapy Practices of Georgia, LLC

3750 Palladian Village Dr., Suite 320 Marietta, GA 30066 Tel: 770) 792-0079

Credit Card Authorization

*when paying for another adult's services (anyone over 18)*
Last Name, First Name*
(Last Name, First Name)*

By signing this document, I acknowledge that I have read the cancellation and billing policies. I understand and agree to take responsibility for the financial obligation of the client indicated on this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I understand that I must cancel my financial obligation in writing.
I am authorizing Healing Psychotherapy Practices of Georgia, LLC to charge my credit card for the services of this client
Billing Address*
City*
State*
Zip*
Card Holder Signature*

Clear
Date*

MonthDayYear
Date
Card*
Expiration Date*

MonthDayYear
Date
Name as Printed on the Card*
Security Code: (3 digit or 4 digit code on card)*
THERE IS NO PAPER COPY OF THIS DOCUMENT. THIS IS UPLOADED TO OUR HIPAA COMPLIANT ELECTRONIC HEALTH RECORD.
Should be Empty: