Credit Card Authorization | North Shore Counseling Solutions

Credit Card Authorization Form

First name

Last name

Card Number

Expiration Date

CVV

Billing Zip Code

Authorization

By your electronic signature of this form, you authorize charges to your credit card for services rendered. These charges will appear on your bank/credit card statement as North Shore Counseling Solutions and/or Tai Pryjma, LICSW. You have the right to request a paper copy of this document.

I authorize North Shore Counseling Solutions and/or Tai Pryjma, LICSW to charge my credit card.

CANCELLATION POLICY: I also agree that my credit card can be charged for any session that is not cancelled at least 48 hours prior to the scheduled session.

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify North Shore Counseling Solutions and/or Tai Pryjma, LICSW in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

I have read and agree to the payment authorization.

Signature

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