lifeskills_Payment

AUTOMATIC PAYMENT AUTHORIZATION FORM
We require all families to have a form of payment on file.

Please complete information for your desired payment method below:

CREDIT CARD PAYMENT - there is a 3.25% service charge for credit card use
Card Type
Is this card linked to an HSA or FSA account?

YesNo
Card Account Number: First 4
Card Account Number: middle numbers
Card Account Number: Last 4
CVN
Expiration
Name of Cardholder
Billing Address
Zip Code
ACH/DEBIT PAYMENT
Bank Account Type
Name on Account
Bank Name
Bank Routing Number (can be found on check)
Account Number
I authorize The Center for LifeSkills, LLC/Stefanie Peck, to debit or charge my account or credit card for services rendered. In addition, as per the signed Service Agreement, I understand my account will be charged in the event that proper cancellation procedures are not followed as noted on the Registration and Policy Form. (initial here)
I understand that it is my responsibility to inform The Center for LifeSkills, LLC/Stefanie Peck, of any changes to my account including address, zip code, expiration dates, account numbers and security codes. I understand I will be responsible for any bank chargeback fees if this information is not updated. (initial here)
Weekly copays, co-insurance payments, and private pay sessions will be processed the day of or after the session date. A receipt will be emailed and an invoice for services rendered may be requested at any time. (initial here)
THERAPY SERVICES PAYMENT OPTIONS:
Please choose one
Parent Name
Payment confirmation email address
example@example.com
Child's Name and DOB
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

AUTOMATIC PAYMENT AUTHORIZATION FORM

ACH/DEBIT PAYMENT

THERAPY SERVICES PAYMENT OPTIONS: