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.


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