Card Authorization Form


Jennifer Daniels, PhD, LCPC
175 Olde Half Day Road, Suite 140-9
Lincolnshire IL 60069


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:

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Signature Certificate
Document name: Card Authorization Form
lock iconUnique Document ID: a7784abe0cbe10afd90d9fb689f57c90a009c634
Timestamp Audit
August 13, 2021 5:51 am CDTCard Authorization Form Uploaded by Jennifer Daniels - IP