I authorize Best Practice Psychotherapy, LLC to keep my signature on file and to charge my credit/debit card for:
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Fee of $75.00 charged for missed appointments or cancellations with less than 24 hours notification as stated in the signed Payment Contract for Service. *This applies to private pay and commercial insurance clients only
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All balances not paid by insurance or other 3rd party payers after 60 days.
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Recurring charges (ongoing treatment) as per amounts stated in the signed Payment Contract with the practice. *This applies only to private pay clients
I understand that this form is valid for one year unless I cancel the authorization through written notice to this practice.
