Electronic Payment Authorization & Policy

Please complete the following information for our records. Your information will be transmitted securely using the highest encryption methods possible for your safety.

I authorize Relationship Center of South Florida (RCOSF) to keep my signature on file and to charge my credit/debit/HSA card for services rendered. I authorize RCOSF to charge my credit/debit/HSA card using internet-based transaction services and confirm that the use of this service does not violate confidentiality.

Charges to this credit/debit/HSA card may include:

Fees for counseling, psychotherapy, or psychological testing
Missed appointments
Appointments cancelled with less that 48 hours notice
Fees for course materials or assessments used in therapy

I understand that this form will be securely stored in my confidential file and will remain valid for the duration of my treatment with the Relationship Center of South Florida., PA. I can modify this form or revoke consent at any time through written notice to the Relationship Center of of South Florida, PA. I agree to notify the Relationship Center of of South Florida immediately of any change in credit/debit/HSA card information.

Name(Required)

First Last

Date(Required)

Responsible Party Billing Name

Please provide the name as shown on the card:

First Last

Billing Address(Required)

As registered with the card account:

Street Address City State ZIP Code

Phone(Required)

Email(Required)

My card is a:(Required)

Credit Card

Debit Card

Card type:(Required)

Visa

Mastercard

American Express

Discover

Card Number(Required)

Expiration Date(Required)

Security Code(Required)

Three digits shown on back of card or four digits on the front (AMEX only)

Center Information

Therapy & Counseling

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