Pathways Christian Counseling

232 W. Hardin St, Findlay, OH 45840

419-423-7812 419-423-9877 (fax)

Credit Card Authorization Form

(Optional)

This form is used to assist clients in being responsible for fees incurred in the counseling process. Please fill this out and return.

I hereby authorize Pathways Christian Counseling to charge my (circle one)…

Visa MasterCard American Express Novus Diners Club Discover

…for my deductible amount and/or copayment amount (where insurance applies) or for the full amount of my fees (as agreed upon with my counselor). I understand that no charges to my credit card will be made in advance of charge incurred through sessions.

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PRINTED NAME: ____________________________________________

CARD NUMBER: ____________________________________________

EXPIRATION DATE: _________________________________________

YOUR ZIP CODE: ___________________________________________

CREDIT CARD BILLING ADDRESS (home billing address)

(needed by credit card companies for verification of ownership of card):

____________________________________________________________

CVV NUMBER (last three digits above signature on the back of the card):

____________________________________________________________

SIGNATURE AND DATE:______________________________________

For clients with a previous balance: Please charge my credit card in the amount of $_______ per month until my balance is paid in full.