Credit Card Authorization Form

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This form is to update your credit card on file with Telepsychiatric Bridge Services.

Email *

First Name (as it appears on the credit card): *

Last Name (as it appears on credit card):
*

Relationship to Patient:
*

Phone Number: *

Credit Card Type:
*

Credit Card Number: *

Expiration Date:
*

CVV Code: *

Zip code associated with Credit card billing address:
*

I authorize Telepsychiatric Bridge Services, LLC to charge this credit/debit card for any and all payments, patient responsibility portions of my insurance explanations of benefits (if applicable), fee for the completion of any forms and/or letters I request and missed/no-show or late appointment fees.

I certify that I am an authorized signer on this card and that the credit card number and signature below are the same as those on file with the credit card issuer.

By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure. (required)

I am the parent/guardian of this patient

Other:

Required

Please type your name to sign below: *

Today's Date: *

YYYY

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