Credit Card Acknowledgement Form
Psychiatric Empowerment Services, PLLC Credit Card Policies and Authorization
In adherence to our practice policies, we ask each client to keep a current credit card authorization form on file in the evert that you cannot or do not pay fees that are outstanding or remain as part of your visit and/or late/cancellation fee.
Your attestation in the form below acknowledges, authorizes, and provides consent to Psychiatric Empowerment Services, PLLC to charge your credit card for any outstanding charges for services at Psychiatric Empowerment Services, PLLC.
Please DO NOT provide a credit card to Psychiatric Empowerment Services, PLLC by way of this form or email. The provider will contact you for the credit card information you wish to provide once this form is completed.