Family Guidance Center, PLLC

Please complete a card of file for co-pays, deductibles, no shows and late cancellations.



CREDIT CARD AUTHORIZATION FOR

Credit Card Authorization Form

After each appointment, your credit/debit/HRA/FSA card will be charged your copay, coinsurance, or deductible amount, unless you provide another form of payment. A credit/debit card on file is required for any no-shows or late cancellations.


If your coinsurance or deductible amount has not yet been determined, an estimate based upon your individual insurance benefit will be charged. Any overpayments will be credited to future appointments, or refunded.

If you have an outstanding balance at the end of treatment your credit card will be charged. 


I authorize Family Guidance Center of Milford, Inc., to charge my credit card for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.


Please fill out credit card information Below


THIS SLIP WILL BE STORED IN OUR SECURE FILES