CREDIT CARD AUTHORIZATION FORM

STEP-BY-STEP PEDIATRIC THERAPY, INC. CREDIT CARD AUTHORIZATION FORM

KAISER PERMANENTE AND PRIVATE PAY CLIENTS ONLY
Please complete all fields. You may cancel this authorization at any time by contacting our office at (626) 330-1538 or (626) 269-3040. This authorization will remain in effect until canceled.
Child's Name*

First NameLast Name
CREDIT CARD INFORMATION
Credit Card Type*

MasterCardVISADiscoverAmerican Express (AMEX)Other
Card Holder Name (As Shown on Card)*

First NameMiddle NameLast Name
Upload Front and Back of Card*

Cancelof
Card Number*
Card Number*
Expiration Date (MM/YY)*
CVV # (AMEX: We will need the 4 digits on the front of the card and the 3 digits on the back of the card.)*
Cardholder Zip Code (from credit card billing address):*
AUTHORIZATION
I authorize Step-By-Step Pediatric Therapy, Inc. to charge my credit card above for agreed upon purchases and to charge my card for any outstanding copay/deductibles that were not charged prior to rendered services. I understand that Step-By-Step Pediatric Therapy, Inc. will notify me via phone call or text message prior to charging my card on file. I understand that my information will be saved to file for future transactions on my account.*

Clear
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STEP-BY-STEP PEDIATRIC THERAPY, INC. CREDIT CARD AUTHORIZATION FORM