Credit Card Authorization Form
All claims are submitted to insurance to determine the client’s responsibility. This credit card will be charged if you have a Co-Pay, Co-Insurance, or Deductible after IPC receives a remittance from your insurance company.
Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.
I authorize Innovative Psychological Consultants, LLC to charge my credit card above for agreed-upon purchases. I understand that my information will be saved to file for future transactions on my account.