Credit Card Authorization

Credit Card Authorization Form

Client Name(Required)
Client Name(Required)
The undersigned agrees and authorized St Croix Therapy Inc to save the credit card indicated below on file.
Name on Card:(Required)
Billing Address(Required)
I authorize St Croix Therapy Inc to process above credit card as "Card on File" and charge in accordance with my insurance policy (e.g., copay, coinsurance, etc.) or the agreed upon payment plan between St Croix Therapy, Inc and me (e.g., patient pay rate, monthly payment, missed appointment fee, etc.). I understand this authorization will remain in effect until the expiration of the credit card account. I acknowledge that I may also revoke this form by submitting a written request to St Croix Therapy, Inc. I acknowledge and agree that this agreement may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature.