Meghan Sasso, LMHC

Credit Card Payment Authorization Form

I strive to make your appointments convenient for you. By signing this form, you give me permission to automatically debit your account for any costs for my services not paid by your insurance, including deductible fees, co-payments, cancellation fees and no-show fees. * Please note that I do charge cards before the actual session to avoid the occasional declined payment methods, so that it can be resolved prior to session & does not take away from your Clinical time.

Please complete the information below:

Billing Address:

City, State, Zip

Phone:

Email:

Account Type:

Account Number:

Expiration Date:

CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX):

Signature

Date

I authorize the above named business to charge the credit card indicated in this authorization form according to the terms outlined above. 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.

Once this form has been completed and submitted, please fill out our Client Packet.

Client Packet