Heredia Therapy Group Credit Card Form_________I am completing this form for...(Required)MyselfMy ChildSomeone elseName of the client receiving Services(Required)Date of birth(Required)Please input the date of birth of the client that is receiving services with Heredia Therapy Group. This will allow us to link the form to their fileTo schedule, please complete this authorization. This form is HIPAA Compliant, and stored on your file. Charges for missed appointments are not covered by insurance and are your sole responsibility. Your credit card will be charged if you fail to show or cancel less than 24 hours in advance of a scheduled appointment. This credit card will be used for copays or coinsurance rate for attended appointments. If you do not show up for your scheduled appointment and have not notified us at least 24 hours in advance, you will be charged to the credit card listed below. If you miss a scheduled appointment without contacting the office, all future appointments will be cancelled in our system, and you are responsible for initiating rescheduling. We realize that clients may need to cancel or change their appointments from time to time. If you must do so, please contact our office by calling 562-821-1491 and leaving a voice message at least 24 hours before your scheduled appointment time. If you miss three appointments with less than 24 hour notice a referral may be provided.Credit Card Information:First Name(Required)As it is written on your cardMiddle NameLast Name(Required)As it is written on your cardSuffixEmail(Required)Card Number(Required)CVC Code (Number on back)(Required)Expiration Date(Required) Billing Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AuthorizationAuthorization: I understand and agree with the above stated policy regarding placing my credit card information on file and I hereby authorize Heredia Therapy Group to charge my credit card accordingly as outlined above. _________I am completing this form for...(Required)MyselfMy ChildSomeone elseName of the client receiving Services(Required)Date of birth(Required)Please input the date of birth of the client that is receiving services with Heredia Therapy Group. This will allow us to link the form to their fileTo schedule, please complete this authorization. This form is HIPAA Compliant, and stored on your file. Charges for missed appointments are not covered by insurance and are your sole responsibility. Your credit card will be charged if you fail to show or cancel less than 24 hours in advance of a scheduled appointment. This credit card will be used for copays or coinsurance rate for attended appointments. If you do not show up for your scheduled appointment and have not notified us at least 24 hours in advance, you will be charged to the credit card listed below. If you miss a scheduled appointment without contacting the office, all future appointments will be cancelled in our system, and you are responsible for initiating rescheduling. We realize that clients may need to cancel or change their appointments from time to time. If you must do so, please contact our office by calling 562-821-1491 and leaving a voice message at least 24 hours before your scheduled appointment time. If you miss three appointments with less than 24 hour notice a referral may be provided.Credit Card Information:First Name(Required)As it is written on your cardMiddle NameLast Name(Required)As it is written on your cardSuffixEmail(Required)Card Number(Required)CVC Code (Number on back)(Required)Expiration Date(Required) Billing Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AuthorizationAuthorization: I understand and agree with the above stated policy regarding placing my credit card information on file and I hereby authorize Heredia Therapy Group to charge my credit card accordingly as outlined above.
