Make an appointment
Our Practice
Counseling Services
Cognitive Behavioral Therapy (CBT)
Marriage & Family Counseling
Children’s Therapy
Addiction Therapy
Telehealth
Careers
FAQs
Blog
Locations
Lackawanna County
Moosic, PA
Downtown Scranton, PA
North Scranton, PA
Clarks Summit, PA
Carbondale, PA
Blakely, PA
Pike County
Matamoras, PA
Northampton County
Bethlehem, PA
Columbia County
Berwick, PA
Bloomsburg, PA
Luzerne County
Kingston, PA
Pittston, PA
Wilkes-Barre, PA
Wyoming County
Tunkhannock, PA
Montour County
Danville, PA
Contact
Card Authorization Form
Home
>
Card Authorization Form
Credit Card Authorization Form
Credit Card Authorization Form
Please complete all required fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.
Card Type
(Required)
MasterCard
Visa
Discover
AmEx
Other
Cardholder Name (as shown on card)
(Required)
Card Number
(Required)
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
Expiration Date
Expiration Date
(Required)
MM slash DD slash YYYY
CCV Number
(Required)
This is the 3 or 4 digit code typically found on the back of your card.
I authorize Dr. John Kuna PsyD. & Associates and / or Mental Health Billing Services, Inc. to charge my credit card for agreed upon purchases and services. I understand that my information will be saved to file for future transactions on my account.
Name
(Required)
First
Last
Email
(Required)
CAPTCHA
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY