Payment Authorization Form

Cardholder First and Last Name

Billing Portal Manager

My signature indicates that I authorize Choice Psychiatric Healthcare, LLC (CPH) to save the above required payment information in FreshBooks (secure and user-friendly accounting site).

I would like CPH to use this credit card method to automatically pay my invoices. I understand there is an additional $10 charge to cover CC fees.

I would like to use my bank account information to actively pay each invoice. I will need to enter my online banking credentials and choose a pre-authorized bank account debit. These credentials are entered in an encrypted/secure format and are used solely for the purpose of allowing me to charge the bank account I choose. Though I have the option to save this information in my private account, using ACH to pay invoices means that I need to enter my portal to pay upon receipt of each invoice. I understand CPH will charge my credit card on file if I have not paid by ACH within two days of service and this will add $10 CC fee.