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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.

Credit Card Information*

Cardholder Name (as shown on card)*

Card Number*

CSV Code*

Zip Code*

Expiration Date*

Customer Signature*

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.

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