Credit Card Update Form

Credit Card Authorization Form
Patient Information Section
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Billing Section
Account Holder Name*
Account Holder Email*
example@example.com
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit Card Authorization Agreement
I authorize North Star Behavioral Health to update my payment method on file for billing purposes.

I understand that my patment method will be used for outstanding balances and fees associated with my care.

I acknowledge that I am responsible for ensuring a valid payment method is on file at all times.

I understand that this authorization remains in effect until I provide written notice of cancellation to the office.
To ensure uninterrupted service, we require a valid payment method on file. You will be redirected to a encrypted portal to enter your credit card details after submitting this form. Your payment information will be stored securely and used only for authorized charges related to your care.*

I acknowledge and agree to the Credit Card Authorization terms above.
Account Holder Name*
Account Holder Signature*

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Date*

MonthDayYear
Date
Important: Next Step After Submission

After clicking “Submit" and confirming signature, you will be redirected to an encrypted page to enter your credit card details.

If you are NOT redirected automatically, please check your browser’s pop-up settings and click the backup payment link in your confirmation email.

For best results, use Chrome, Safari, or Edge.
Should be Empty:

Credit Card Authorization Form

Patient Information Section

Billing Section

Credit Card Authorization Agreement