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Credit Card Authorization

Jewish Family and Career Services of Atlanta
4549 Chamblee Dunwoody Road
Phone 770.677.9389
Fax 770.677.9400
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
I authorize JFCS to charge my credit card on file for future visits with the following clinician/counselor/therapist:
Cardholder name
Credit card number
Expiration date
CVV code
Zip code
In the amount of:
Fee:   Copay  
No-show billable appointments will be charged for clients using insurance, or regular fee for self-pay clients (no insurance) for appointments missed without 24 hour prior notice.  This fee will equal the amount insurance would have paid for the visit (for insured clients) or the private fee amount the client normally pays (for clients not using insurance).
Client Signature
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
JFCS Staff:

Please make sure you make a clear copy of a credit card (three digits on the back of a card are visible; if not you may write it down).
Submit to Dunwoody office and inform a receptionist to charge your client.
Please inform a receptionist to charge your client for every occurring appointment, as well.
Form Updates
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