Authorization for Payment Card Auto-Pay

I authorize Spencer Psychology to store my payment card information on file with Spencer Psychology's  third-party payment processing service for automatic payments. I also authorize Spencer Psychology to charge outstanding balances on my/my authorized user’s account for services, no shows and late cancelations. I agree that no prior notification is required for charges on my card and that this authorization remains in effect until I notify Spencer Psychology in writing or email to admin@spencerpsychology.com.

I understand that:

• Payment is due at the time of service and that I will need to keep a valid credit card on file to be charged after each session.

• A receipt for each payment will be provided, and the charge will appear on my payment card statement.

• Card numbers are not visible to Spencer Psychology staff.

• No shows/cancelation fees are not eligible for payment by a Health Savings Plan (HSA), but if a HSA is used for these fees, the card holder may have to reimburse the HSA account if audited. Spencer Psychology will not know if a card is for an HSA account, and are not liable for clients not following  HSA plan requirements, or for clients not following guidance given by the card holder.

• Due to privacy regulations, Spencer Psychology may not discuss with the card holder any clinical information for the adult client, nor arrangements made with the client about choice of session type, no show/late cancelation fees, or waivers of insurance. These issues will be explained to the client, and it is the client’s responsibility to discuss this with the card holder.

• If I allow another person to use this payment card for services and fees, I am responsible for the charges the client incurs. I understand it is my responsibility to monitor this use with the client and with my payment card statement, and that Spencer Psychology cannot refund legitimate charges to the card that the authorized user/client uses.

• If my card declines and multiple attempts are required to charge the balance for the same session, there may be a processing fee.

•  I may withdraw permission for the use of the card at anytime by notifying Spencer Psychology myself by email to admin@spencerpsychology.com.  I cannot rely sending a message through the client or assume the client has taken over payments. Spencer Psychology will stop charging the card on the date of the notification.

• Refunds cannot be made retroactively from the receipt of the written notice of cancelation.

I have read this consent and agree to the above statements


Last four digits of card:
 
Enter last four digits of card
This card is:

My primary card (replace any other cards on file)

Secondary card (keep primary card on file)

Other (We will contact you)

Client Name:
Enter client name
Electronic Signature of Authorized Card Holder:
Enter your full name
Date:


Note: After Clicking Submit, you will need to enter your card information.