CREDIT CARD BILLING FORM I authorize payment for services by credit card, to be made to Psychology of South Florida for services performed by rendering providers. *Your Name : *Name on Credit Card: *Credit Card Type:VISAMASTERCARDAmerican ExpressOther/HSACredit Card Number: *Expiration Date: *V-Code *Billing Address Zip Code: *Amount to be charged: One-time fee of $and/or per session fee of $*My signature below indicates approval for the billing of the above one-time fee and/or per session fee on a recurring basis to my credit card. I also agree to credit card payment of fees associated with failure to provide appropriate notice of session cancelation, as outlined in the patient agreement. My approval continues until cancelled (verbally or in-writing) or until a maximum date of up to one year from Today’s Date. *Authorized Signature: *Today's date *Send Message
