Credit/Debit Card Authorization Child Name Parent Name I authorize Advantage Speech Therapy Services to maintain my credit/debit card on file. I understand that this card will only be used if:My child’s account has been delinquent for more than 30 days and I have not made any effort to make payment arrangements.* YES NO My child’s appointment was canceled with less than 24 hours notice.*($55 or 50% of insurance rate-per policy form) YES NO It was a no show for a scheduled appointment.*($55 or 50% of insurance rate-per policy form) YES NO I want to set up automatic payments when an invoice is created.* YES NO *There will be a processing fee attached to the use of your card. Date MM slash DD slash YYYY Patient Name:* Cardholder Name:* Cardholder Address:* City:* State:* Zip:* Type of Card Visa Mastercard Amex Card#* Expiration:* CVV:* NameThis field is for validation purposes and should be left unchanged.
