Card Authorization Form - Dr. John G Kuna and Associates

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.

Client Name(Required)

First Last

Used to apply the payment to the correct balance.

Debit or Credit(Required)

* 3% surcharge will be added to all credit card payments - no surcharge for debit card payments

Card Type(Required)

Cardholder Name (as shown on card)(Required)

Card Number(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Expiration date(Required)

CVV Number(Required)

This is the 3 or 4 digit code typically found on the back of your card.

Would you like to create an automatic payment plan?(Required)

Yes

Amount(Required)

Frequency(Required)

Date you would like automatic payment to begin(Required)

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.

Email(Required)

CAPTCHA

Signature(Required)

Date(Required)