Credit/Debit Card Authorization

  • I authorize Advantage Speech Therapy Services to maintain my credit/debit card on file. I understand that this card will only be used if:
  • ($55 or 50% of insurance rate-per policy form)
  • ($55 or 50% of insurance rate-per policy form)
  • *There will be a processing fee attached to the use of your card.

  • This field is for validation purposes and should be left unchanged.