Therapy Fees/Credit Card Authorization Form

Valerie Andersen, Psy.D.

Licensed Psychologist | PY9730

Fees / Credit Card Payment Authorization Form

**If you are using iINSURANCE to cover the cost of therapy services, this authorization will be used solely for the purpose of MISSED / CANCELED appointments, ART sessions and any PRORATED FEES associated with sessions exceeding 60 minutes. **

Please sign and complete this form to authorize Dr. Valerie Andersen, PSYD. to process your credit / debit card once services have been rendered. *Credit card information is not to be added to this form and will be obtained verbally by consent to protect sensitive information and will be vaulted in an encryted (aka "tokenized") format within the PSI approved, payment processing application, "Intuit GoPayment."* By signing this form you give permission to debit your account for the amount indicated below. When a patient is not present for a credit card authorization, the signature line will read "Pre Auth" as notification that the therapy service charge has been processed through the payment application listed above, and that you have authorized the transaction in advance. The payement will appear on your credit card statement as "ACH DEBIT INTUIT" and the invoice will include an authorization code for reference and security purposes. This agreement provides permission for scheduled session fees, no-show/missed appointments and late cancellation fees. It does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

First Name Last Name authorize Dr. Valerie Andersen, PSYD. to charge my credit card account through Intuit GoPayment in the amount of $190.00 for scheduled therapy sessions and prorated at $50.00 on the quarter hour for any session time exceeding 60 minutes. ART sessions, typically 90 minutes, are billed at a flat-rate of $275.00 (*Insurance patients $100.00*). I also authorize a charge equal to full cost of the scheduled service if I do not provide 24 HOURS notice before a missed session or do not appear for a scheduled session. Exceptions to be discussed directly with the provider.

Billing Address*

Billing Address

Street Address Line 2

City State Zip

Phone*

Email*

example@example.com

Cardholder Name*

SIGNATURE*

DATE*

Date

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the purpose described above, for the amount indicated above only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

10300 49th Street North, Clearwater, FL 33762

Phone (321) 368-9646

drval.psych77@gmail.com