Credit Card Authorization Form The Loop SLL

This form is HIPPA compliant and encrypted so your information will be kept secure!

I authorize The Loop Speech, Language, and Learning to charge the credit card indicated in this authorization form according to the terms outlined in my patient agreement. This payment authorization is for therapy services, for the amount invoiced by the practice, and is valid for ongoing monthly and weekly services. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

Name on Card

Billing Zip Code

Email Address for Receipts

Card Type

Visa Master Card American Express Discover HSA Other

Explain Below

If other, please explain

Card Number

Expiration Date

Security Number (3 digits on back of card)

I authorize The Loop SLL to charge fees rendered for therapy services to the credit card provided herein.

I understand that the provided credit card will be charged for services rendered at the end of the week and that I will receive an emailed invoice as receipt of payment.

I understand I am responsible for any additional fees that occur due to the credit card being denied and/or transactions being disputed.

Signature

Date

Your information will be encrypted.