Common Contracts

2 similar Credit Card on File Agreement contracts

Credit Card on File Agreement
Credit Card on File Agreement • December 23rd, 2021

We have implemented a policy which enables you to maintain your credit card information securely on file with Richmond Creative Counseling (RCC). In providing us with your credit card information, you are giving RCC permission to automatically charge your credit card on file for your (or any other patient(s) you have listed on this form) co-pays/ co-insurance, outstanding balances, missed/ canceled appointment fees, services, and/or products.

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Credit Card on File Agreement
Credit Card on File Agreement • September 3rd, 2021

We have implemented a policy which enables you to maintain your credit card information securely on file with Richmond Creative Counseling (RCC). In providing us with your credit card information, you are giving RCC permission to automatically charge your credit card on file for your (or any other patient(s) you have listed on this form) co-pays/ co-insurance, outstanding balances, missed/ canceled appointment fees, services, and/or products.

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