Please read and sign the following. This authorization will remain in effect until cancelled and can be withdrawn at any time by notifying Cornerstone of Hope.
- I acknowledge that my card will be kept on file within Cornerstone of Hope’s HIPAA compliant payment system.
- I acknowledge that my card will be charged the full rate specified before or after each scheduled/agreed upon counseling session.
- I acknowledge that my card will be charged for any unpaid balance, including late cancellations and no show appointments.
- I acknowledge that I have the right to access all receipts indicating transactions that have been charged to my account at any time.
- I agree to notify the vendor in writing of any changes in my account information and/or termination of this authorization at least 15 days before the next scheduled billing charge date. If a payment/charge is rejected due to Non-Sufficient Funds (NSF) I also accept that the merchant may process the charge again within 30 days at their discretion and that an additional charge may be levied for each returned payment.
- I certify that I am the owner of the credit card described below and will not dispute the scheduled payments with my bank/credit card company, provided that the transactions correctly correspond with the terms written on this authorization form.