Credit Card on File
Payments are due at the time of service. One Love Counseling requires a credit, debit, or flex spending/HSA card on file in order to schedule sessions. The credit card on file can be used in order to pay for any copays, co-insurance, deductibles, no shows/late cancellations or out of pocket payments if no other payment method is used at the time of the session or if a late cancellation or no show is incurred (in which case, the credit card on file will be charged our full fee on the day of scheduled session). Clients may also pay by cash or check at each session. Your credit card will be stored in a HIPAA compliant electronic health system and this document will be safely destroyed.
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Client Name: *
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Cardholder Name:
(If different than above)
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Credit Card Number: *
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Expiration Date: *
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Billing Zip Code of Credit Card: *
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Security Code: *
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Cardholder’s Digital Signature: *
Typing your name is your legal agreement to the terms.
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Today's Date: *
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I understand that by signing above, I am authorizing One Love Counseling to charge my card in the manner indicated by my name/details above. These balances may include co-pays, co-insurance amounts, out of pocket payments, deductibles, no show or late cancel fees. *
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