The Counseling Center Secure Credit Card Payment Authorization Form

Please be reminded that payment is due at the time of the service, so as a convenience, if you would like to leave your credit card on file, it will be charged after each visit  If you would like to pay your bill using your credit card, please supply the following credit card information. Please understand that it could take multiple days for this payment to be processed. Please include your email address so we can verify that we have received your information that that we have processed your payment
0/200 characters
Visa
MasterCard
American Express
Discover
CREDIT CARD

Flex Spending Account (FSA)

Health Savings Account (HSA)

Account Balance Due on Account

Prepayment or Deposit for Services Yet to be Rendered
Security codes are
found on the back
of the card or front
of the American Express

Additional information or intructions pertaining to payments or use of credit card. 
In addition to my current payment above, I would like to leave my Credit Card information on file for future payments. 
Please check any/all requests for future use of your credit card
Future Co-Pays and Balances Due - if not otherwise paid for in person at the time of your visit *
~~By selecting 'Yes' you are agreeing to all future co-pays and balances being charged to this credit card.~~ *
* If yes and you have submitted an FSA or HRA card, please also consider submitting a regular credit or debit card to cover when your FSA or HRA is depleted.
Charges for medication refills requested by phone
* If yes and you have submitted an FSA or HRA card, please also submit a regular credit or debit card for non-insurance billable services
Long Term Payments per Payment Plans, if applicable
Educational Liaison Services
* If yes and you have submitted an FSA or HRA card, please also submita regular credit or debit card for non-insurance billable services
Testing Co-Insurances
Non-Covered Charges for Educational Testing or Comprehensive Report Writing.
* If yes and you have submitted an FSA or HRA card, please also submit a regular credit or debit card for non-insurance billable services

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I understand that my typed name above shall have the same legal and binding authority as my handwritten signature.