Authorization for Payment

I authorize Cognitive Therapy and Training Center, Inc., to charge my Visa or Mastercard for any unpaid fees, including:

Fees for services (therapy sessions)
Missed appointments that are not cancelled with at least 24 hour notice
Superbills requested more than 4 weeks after initiation of treatment will be charged an admin fee of $25/hour

This authorization is ongoing and will be automatically revoked six months after the last date of service Until that time, I authorize payments as described above to Cognitive Therapy and Training Center, Inc. I understand that I may pay only via Visa or Mastercard.

I understand that this six-month time period may be required to determine final amounts due and settle my account, and that my credit card may be billed during this time. Expiration or cancellation of a credit card does not relieve me from any unpaid debts.

Credit Card Number:

Expiration Date:

V-Code:

Billing Address:

Billing Zip Code:

Client name:

Client Signature

Date

Zelle is the preferred method of payment for Cognitive Therapy and Training Center. Please pay by Zelle prior to the session or by the end of the date of service.

Here are the steps to begin sending money through Zelle.

1. Download the mobile banking app of your bank account (Chase, Bank of America, Wells Fargo, etc)

2. I will send you a payment request from my Zelle account, which will go to your email or phone number attached to your Zelle account.

3. Please follow the link to view the request. Thanks for selecting "send" to send the payment.

Superbills can be provided if you have PPO insurance. If you would like a superbill to submit to your insurance company, please provide the following information:

Name of insurance company:

Member ID number:

Group ID number:

Telephone number:

Your information will be encrypted.