Authorization for Automatic Credit Card Payment

To guarantee payment for services rendered and/or missed appointments. Please provide documentation of a major credit card. I authorize NorthStar Counseling Group to charge my credit card a $100.00 fee due to a missed appointment or a late cancellation (appointments cancelled without 24 hours’ notice). Please note that missed appointments and late cancellations will NOT be covered by insurance. I understand that if my credit card is charged, I may be charged interest per my agreement with my credit card company. This interest can be substantial, and the amount owed will increase with each partial payment to the credit card company if not paid in full. I understand that this authorization is valid until I cancel the authorization through written notice to NorthStar Counseling Group or unless otherwise indicated.

THIS FORM IS SENT TO AN ENCRYPTED EMAIL ADDRESS THROUGH AN SSL CONNECTION

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