Card Authorization Form | Carolynn Brusseau


 

Carolynn Brusseau, MA, LPC
Access Counseling Services, Inc.
175 Olde Half Day Road, Suite 140-9, Lincolnshire IL 60069
19 N. County Street, Waukegan IL 60085
carolynn@jdanielsphd.com | 312-600-5367
jdanielsphd.com

 

Debit/Credit Authorization Form

 

Name on the Card:  

 

Type of Card:

 

Account Number:  

Expiration Date:   Security Code:   

 

Billing Address:  

City:       State:      Zip:  

 

By signing this form you authorize charges to your card for:

 

  The amount of each session

   The amount of copay for each session

   The amount of a missed session

   Your signature also authorizes charges for the balance owed on your account should you fail to make payments by debit/credit card or by other means in a timely manner. 

 

 

 

Leave this empty:

Signature arrow sign here


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Document name: Card Authorization Form | Carolynn Brusseau
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Timestamp Audit
May 9, 2023 11:46 pm CDTCard Authorization Form | Carolynn Brusseau Uploaded by Jennifer Daniels - jennifer@jdanielsphd.com IP 72.207.59.93
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