Credit Card Authorization FormPlease complete all fields. You may cancel this authorization at any time by submitting a signed request to do so. This authorization will remain in effect until cancelled.Cardholder Name (as shown on card)* First Last Name (if different than cardholder name) First Last Date of Birth* Month Day Year Card Number* Expiration Date* CVC Code* Card Type* Visa Mastercard American Express Discover Is this your primary card on file?*Primary cards are the default card used for any patient balance, unless otherwise specified. Yes No (if not, you are required to list an additional card on file below) How would you like this card to be used?*(ex. patient insurance responsibilities such as copay and deductible, or herbs and products, etc.)Is this an HSA or FSA card?* Yes (an additional NON HSA/FSA card is required to be kept on file) No Additional Card on FileWhen using an HSA or FSA, Holistic Health Associates requests you keep an additional card on file for herbs and non-service related expenses, as well as in the event your HSA funds run out. You may also elect to keep an additional card on file for specific purchases.Cardholder Name (as shown on card) (Additional Card on File (non-HSA/FSA)) First Last Card Number (Additional Card on File (non-HSA/FSA)) Expiration Date (Additional Card on File (non-HSA/FSA)) CVC Code (Additional Card on File (non-HSA/FSA)) How would you like this card to be used?*(ex. patient insurance responsibilities such as copay and deductible, or herbs and products, etc.)Is this your primary card on file?*Primary cards are the default card used for any patient balance, unless otherwise specified. Yes (by not selecting the initial card entered as your primary card, you are required to select “yes” here) Contact InfoBilling Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Phone*Card approved for the following additional people. By listing additional names here, you authorize Holistic Health Associates to take payment on these respective accounts for any services rendered, purchases and/or balances with the credit card listed above.Consent* By signing below, I authorize Holistic Health Associates to charge my credit card above for services rendered, purchases and/or balances as outlined in the Financial Policy. I understand that my information will be securely saved on file for future transactions on my account.Signature of Patient, Legal Representative, or Parent/Guardian*By completing this box, you have digitally signed the Holistic Health Associates Credit Card Authorization form. Date* Month Day Year Printed Name of Patient, Legal Representative, or Parent/Guardian* Relationship to Patient EmailThis field is for validation purposes and should be left unchanged.
