Psychvisit

Credit Card Authorization

Please complete this form to authorize your credit card on file with Psychvisit.

Patient Full Name *

Date of Birth *

Phone Number *

Email Address *

Card Number *

Expiration Date *

Security Code (CVV) *

Billing ZIP Code *

Credit Card Authorization Agreement

I, the undersigned, authorize Psychvisit to charge my credit card on file for the following:

Co-payments and deductibles at the time of service
Outstanding balances after insurance processing
Late cancellation fees (less than 24 hours notice): $50
No-show fees: $75
Any services rendered that are not covered by insurance

I understand that Psychvisit will attempt to notify me via phone, email, or text message before charging my card for balances over $100. For amounts under $100, charges may be processed without prior notification.

I understand that I have the right to revoke this authorization at any time by providing written notice to Psychvisit. Such revocation will not affect any charges processed prior to receipt of the written notice.

This authorization remains in effect until I cancel it in writing or until my relationship with Psychvisit ends.

I have read and agree to the Credit Card Authorization Agreement above. I authorize Psychvisit to charge my credit card as described.

Signature *