Commonwealth Psychology Associates Payment Authorization Form
Personal Information
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First Name:
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Last Name
Billing Information
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Name on Card: (Please Print as it Appears on the Card)
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Card Type:
Choose One
Visa
MasterCard
Discover
American Express
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LAST 4
digits of Card Number
XXXX-XXXX-XXXX-
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Billing Zip Code:
Authorization
I authorize Commonwealth Psychology Associates, LLC to charge the card listed above for professional services rendered, by presenting this card at each visit, or, by giving verbal permission.
This authorization shall remain in effect until I notify Commonwealth Psychology Associates, LLC of my intent to withdraw this authorization.
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Signature
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Date
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