Lifetime Insight 2026 CC Auth Form

2026 Credit Card Authorization Form
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who will be financially responsible for charges not paid by insurance (may include copays, deductibles, co-insurance, no-show fees, and non-covered services, if applicable)?
Name of Guarantor (person financially responsible):
Relationship to patient:
Phone Number of Guarantor

Area CodePhone Number
Email of Guarantor:
example@example.com
I hereby authorize Lifetime Insight LLC to charge the credit card provided (using the redirect link after submission) for appointments (deductibles, copays, co-insurance, non-covered services, etc), sessions, and services, or for other reasons as stated in Lifetime Insight Consent, Policies & Payment Agreement.

I understand that this card will be stored securely and will be AUTOMATICALLY charged for the following:

NO SHOWS/LATE CANCEL VISITS:
- 45 minute or longer scheduled visit: $425
- 25 minute scheduled visit ("extended follow-up"): $250
- 15 minute scheduled visit ("brief follow-up"): $175
SELF PAY RATES:
- 15 minute scheduled visit: $235
- 25 minute scheduled visit: $320
- 45 minute scheduled visit: $425
- 55 minute scheduled visit: $495
Once submitted, I understand that I will be directed to a secure form to enter my credit or debit card information. This card will be stored securely with a PCI-compliant processor and used only in accordance with the authorization terms above.
Signature
Should be Empty:

2026 Credit Card Authorization Form