Credit Card Guaranty of Payment - Alison Howard
Alison M. Howard, Psy.D., M.Ed
Clinical Psychologist
4601 Connecticut Avenue, NW Suite 20
Washington, DC 20008
202-368-3501
Credit Card Guaranty of Payment
As a service to my patients, I offer credit card processing in my practice. Please read the following carefully:
If you choose to use your credit card as your method of payment, your card will be charged per session and you will receive a bill at the end of each month detailing the charges and the service codes. If you are using a credit card, your bill will reflect a zero balance.
Please read and complete the following:
I understand that Dr. Howard will be billing me for therapy for each session we meet, or for the agreed upon amount for evaluation services. I also understand that I am responsible for payment of services, and that if for some reason the credit card is cancelled or declined, I will pay the invoice in another way.
I understand that Dr. Howard uses the credit card company: MerchantWarehouse/Cayan. On my credit card statement the charge will appear with Dr. Howard’s phone number as the merchant. I understand that this form is valid unless I cancel the authorization in writing.
_______________________________________________________________________________
Patient Name
_______________________________________________________________________________
Cardholder Name (if different from the patient)
_______________________________________________________________________________
Cardholder Billing Address (including zip code)
_______________________________________________________________________________
Type of Credit Card (Visa, Master Card, or Discover)
_______________________________________________________________________________
Credit Card Number Security Code
_______________________________________________________________________________
Expiration Date
I authorize Dr. Alison Howard to charge my credit card for services rendered by Dr. Alison Howard:
___________________________________________
Signature Date
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- ford credit card payment center
- credit card payment calculator
- credit card monthly payment calculator
- credit one bank credit card payment online
- wells fargo credit card payment address
- bank of america credit card payment address
- credit card payment calculator payoff
- credit card minimum payment calculator
- credit card payment amortization schedule
- wells fargo credit card overnight payment address
- bank of america credit card payment online
- credit card notification of death