Credit Card Authorization Form

Patient's Information

Payment

• All payment is due at your session. Patients may not carry a balance.
• You may pay for sessions by cash, credit card, or check.
• Make checks out to Bucks County Anxiety Center. There is a $30 fee for returned checks.
• Teletherapy sessions are pre-billed.

By filling out the information below, you acknowledge that any outstanding balances will be automatically charged to your credit card.

Credit Card Information

Use of Credit Card Information by Bucks County Anxiety Center:

• By signing this form, you agree to pay all applicable fees associated with using your insurance such as co-pays, co-insurance, rejected claims or any other type of outstanding balance.
• By signing this form, you agree to pay all fees you are charged for any services provided by Bucks County Anxiety Services if you are paying out of pocket or for services not covered by insurance.
• By signing this form, you agree to provide Bucks County Anxiety Center with a credit card number that will be kept on file and will be charged if you do not pay your balance.
• Co-pays, co-insurance, and out of pocket fees are due at each session. They can be paid by cash, credit card, or check. Checks will be made out to Bucks County Anxiety Center.
• You are responsible for all fees that are not paid by your insurance company such as coinsurance or any rejected claims. Balances must be paid immediately, or your card will be charged for the amount you owe.
• Phone sessions are charged the day they take place.
• Late cancellations are charged the day they occur.
• For your convenience, we can charge your balance to your card on file after each session.

Use of Credit Card Information by Bucks County Anxiety Center:

• By signing this form, you authorize Bucks County Anxiety Center to use the credit card information you are providing to pay for services provided to the patient as well as any fees they incur such as late cancellations, not showing to appointments, and other charges explained below.
• By signing this form, you agree to pay all applicable fees associated with the patient using insurance such as co-pays, co-insurance, rejected claims or any other type of outstanding balance.
• By signing this form, you agree to pay all fees the patient will be charged for any services provided by Bucks County Anxiety Center if the patient is paying out of pocket. If the patient is using insurance, you agree to pay for services not covered by insurance.
• By signing this form, you agree to provide Bucks County Anxiety Center with a credit card number that will be kept on file and will be charged if the patient does not pay their balance.
• Co-pays, co-insurance, and out of pocket fees are due at each session. They can be paid by cash, credit card, or check. Checks will be made out to Bucks County Anxiety Center.
• The patient is responsible for all fees that are not paid by their insurance company such as coinsurance or any rejected claims. Balances must be paid immediately, or your card will be charged.
• Phone sessions are charged the day they take place.
• Late cancellations are charged the day they occur.
• For the patient’s convenience, we can charge their balance to your card on file after each session.
• For privacy reasons, we cannot discuss anything related to a patient over the age of 14 (e.g., charges,attendance, cancellations, sessions, treatment) even though we are charging your card. The patient must sign consent first.