CREDIT/CHARGE/DEBIT CARD PREAUTHORIZATION



Kate J. Heit, MA, LPC

Towne Square Professional Bldg. 303*277*9407 Office

5738 Olde Wadsworth Blvd. kjh1050@

Arvada, CO 80002

CREDIT/CHARGE/DEBIT CARD PRE-AUTHORIZATION

If you intend to use a credit/charge/debit card for fees, please complete this page.

I authorize Kate J. Heit, MA, LPC to keep my signature on file and to charge fees, or partial fees, to my credit, charge or debit card account for services provided to

_____________________________________________

Client Name: (please print)

I understand that this authorization is valid until canceled in writing. I understand that charges for ongoing services will normally be posted to my credit card account within a week of each service date.

I agree that if I have any problems or questions regarding charges to my account, I will contact Kate J. Heit for assistance. I agree that I will not dispute any charges with my credit card company unless I have first attempted to rectify the situation directly with

Kate J. Heit and those attempts have failed.

Cardholder Name (please print):

______________________________________________________________________________

Billing Address (where statements are mailed):

______________________________________________________________________________

City:__________________________________ State: __________ ZIP: __________________

Card Type (circle one): Visa MasterCard Discover

Account No.: __________________________________________________________________

Exp. Date: ______________ V-Code: ____________

(The V-Code is a 3–4 digit number on the back of your card, located after the account number).

Cardholder Signature: _______________________________________ Date: ____________

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