Optional Credit/Debit Card Authorization Form

Rainier Behavioral Health

Please correct the errors described below.

If you would like to have your credit/debit card or HSA/FSA on file, Rainier Behavioral Health can run your card for any balances accrued on your account.

Client Information

A copy of your receipt can be emailed after each debit

Card Information

By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

Signature

Type your full name

Your information will be encrypted.

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