Credit Card Authorization | Life Management for

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LIFE MANAGEMENT FOR ADULTS, PLLC

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PAYMENT AGREEMENT CREDIT CARD AUTHORIZATION

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Credit Card Information

Cardholder Name (as shown on card):

Phone

Email

Card Type:

MasterCard

VISA

AMEX

HSA/FSA

Last 4 digits:

Exp Date:

Zip Code

For Patient Account belonging to:

I authorize Life Management for Adutls to charge my credit card above for agreed upon payment schedule. I understand that my information will be saved to file for future transactions on my account.

Signature

enter date authorized

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