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)
Address(Required)
MM slash DD slash YYYY
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)
MM slash DD slash YYYY