BALZ05 Credit Card on File Form

CREDIT CARD ON FILE AUTHORIZATION & CONSENT FORM

Para Español, seleccione del menú desplegable en la esquina superior derecha.

To streamline billing and reduce administrative time, Balanced Mental Health of Arizona requires that a valid credit or debit card be kept securely on file. This card will only be charged for applicable fees as outlined below.

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

I, the above named patient, authorize Balanced Mental Health of Arizona to keep my credit/debit card information on file and to charge my card for the following purposes:

Copayments or coinsurance amounts
Deductibles as determined by my insurance
Services not covered by insurance
No-show or late cancellation fees (as outlined in the practice policy)
Self-pay services (if applicable)

I understand that my credit card information will be stored securely in compliance with applicable laws and data security standards and will only be accessed by authorized personnel.

PATIENT RIGHTS & RESPONSIBILITIES

I will be notified prior to any non-routine charges.
I may revoke this authorization at any time in writing.
I am responsible for updating any changes to my credit card information.
If a card is declined, I agree to provide a valid form of payment promptly.

CARDHOLDER INFORMATION

Name on Card

First Name

Last Name

Card Type

Visa

MasterCard

AmEx

Discover

Last 4 Digits of Card

Expiration Date

Billing Zip Code

By signing below, I acknowledge and consent to the terms outlined above.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient or Authorized Representative Signature