Price: $15.00
Format: Editable PDF | 1 Page | Instant DownloadDescription:
Protect your practice from payment disputes with this clear, compliant Credit Card Authorization Form. Designed to meet the language banks look for during charge investigations, this one-page form ensures clients agree to keep a valid card on file and authorize automatic charges for balances due, cancellations, or missed appointments.Includes:
Explicit card-on-file consent language
Automatic charge authorization statement
Policy notice for declined or missing cards
Signature and date acknowledgment fields
Fillable PDF format with GBBS branding
Perfect for:
Therapy, psychiatry, or behavioral health practices that require card-on-file policies to stay compliant and protect revenue.
* Created by Golden Bee Billing Services, LLC — experts in behavioral health billing, compliance, and operational design.
Taxes included in price.
Credit Card Authorization Form (2025 Edition)
© 2025 Golden Bee Billing Services, LLC
All rights reserved. This document is an original work created by Golden Bee Billing Services, LLC and may not be copied, resold, or distributed without written permission.This template is intended for informational and administrative use only. It does not constitute legal advice and should be reviewed or customized to fit your individual practice policies and state regulations before use.
Licensing Your purchase includes a single-use commercial license for use within one private practice. You may print, fill, and digitally store the form for client use within your practice, but redistribution, resale, or reproduction for others is not permitted.
Pricing Note All prices listed in The Hive Shop include applicable taxes. No additional fees will be added at checkout.