Credit Card Authorization Form


CREDIT CARD AUTHORIZATION FORM
COLORADO COUNSELING CENTER, PLLC (“CCC”)

    

Colorado Counseling Center, PLLC (“CCC”) requests that you confirm limited credit card information below to verify your authorization for CCC to use this specific card. To keep your information secure, please do not transmit your full card number electronically below. 

To provide your full credit card information (name, number, expiration date, cvv code, and zip code), please contact our office manager over the phone (720-468-0101, ext. 2) or provide the information directly to the counselor at the first therapy session. 

If you choose to pay by credit card your credit card will be charged the full fee after each session, as described in CCC’s Consent, Disclosure, & Policies Form. If you choose to pay by cash or check, your credit card will only be charged if your account is past due and/or for any additional fees you and/or your minor child/ren incur such as longer sessions, late cancellation fees, or no-show fees.

If your credit card payment does not go through, in the event your account remains past due for sixty (60) days, CCC reserves the right to send your account to collections, at any time after your account is considered past due, in accordance with CCC policies and procedures; .

By signing this authorization form, you agree to notify CCC of any changes to your credit card information such as a new expiration date or when your credit card has been cancelled, lost, stolen, or revoked. New card information must be provided and a new form must be submitted if information such as the list of authorized users and the credit card account’s expiration date is amended.

Colorado Counseling Center, PLLC Accepts the following Credit Cards:
Visa, MasterCard, Discover, and American Express (this includes many HSA cards)

Limited Card Information:

Type of Credit Card

This credit card authorization form will remain in effect and on file at CCC unless revoked in writing or until the therapeutic relationship is terminated, at which time, authorization to charge your credit card will be revoked, unless an outstanding balance remains on your account after termination. CCC will not share your credit card information with any third-party without your consent. Your credit card information will be kept confidential.

I hereby authorize CCC to charge the credit card identified above for payment of the counseling fees I or my minor child incurs, which shall include longer pro-rated sessions, late or past due fees, or fees related to cancellations or no-shows. I affirm that I am an authorized user of this card. I understand that my credit card will be billed in accordance with the authorizations listed above.

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Colorado Counseling Center https://www.coloradocounselingcenter.com
Signature Certificate
Document name: Credit Card Authorization Form
Unique Document ID: 6b1c47b63470662312bb3263daeb458158bb59de
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March 7, 2019 2:16 pm MDTCredit Card Authorization Form Uploaded by Annette Thaler - annette@coloradocounselingcenter.com IP 73.153.245.127