Credit Card Authorization Form
This form applies to YES in Psychiatry and its affiliated providers.
- I hereby authorize YES in Psychiatry to securely process and retain my credit card information as a “Card on File.” I understand that this authorization allows YES in Psychiatry to charge my card for any costs associated with services as outlined in the Financial Responsibility Agreement. This authorization will remain in effect until the expiration date of my credit card or until I revoke this authorization in writing.
- I understand that it is the policy of YES in Psychiatry that all patients maintain an active credit card on file prior to receiving services. This card may be used for co-pays, deductibles, self-pay fees, missed appointments, or any amount not covered by insurance.
- I, the undersigned, have read and understand this Financial Responsibility Agreement. I accept full responsibility for payment of any fees not covered by insurance and any self-pay service fees incurred.
For questions, please contact:
689 273 8787 or
info@yesinpsychiatry.com
