This is the full Payment Authorization Form text a client signs when establishing a payment method on file. Placeholders in curly braces are replaced with practice and client details before signing.
Payment Authorization Form
Version: 2026-05-28-v1 · Effective: June 17, 2026
This Payment Authorization Form (the “Authorization”) is entered into between {Client full legal name} (“Client”)
{Client mailing address}
{client email} and {Practice name} (“Practice”)
{Practice address}
{practice email}.
1. Authorization
Client authorizes Practice to charge the credit card, debit card, or bank account on file (the “Payment Method”) for fees owed for services Client receives from Practice, including but not limited to:
- session fees per the schedule in Section 3;
- missed-appointment and late-cancellation fees per Practice’s cancellation policy in Section 4;
- fees for any additional services Client requests in writing (e.g. records preparation, court documents, letters).
2. Payment Method storage and security
The Payment Method is captured and stored using Stripe, a PCI-DSS Level 1 certified payment processor. Practice and The Bowerbirds (Practice’s practice-management vendor) never receive, transmit, or store full card numbers, CVV codes, or bank account numbers. Practice retains only a Stripe-provided token, the last four digits of the card or account, and the expiration date (for cards) for identification purposes.
Client may update the Payment Method at any time by contacting Practice or by following the secure update link Practice will send on request.
3. Fee schedule
{Practice fee schedule will be listed here, e.g. “$165 per 50-minute individual session”.}
Practice will provide written notice to Client at least thirty (30) days in advance of any change to its fee schedule. Client may revoke this Authorization at that time (see Section 7) if Client does not wish to continue at the new rates.
4. Cancellation policy
{Practice cancellation policy will be listed here, e.g. “Full session fee charged for cancellations with less than 24 hours’ notice.”}
5. When charges occur
Charges against the Payment Method will occur automatically:
- upon completion of each session, for the session fee;
- at the time of a late cancellation or no-show, per Section 4;
- upon written agreement between Client and Practice for any additional services.
Client will receive an itemized receipt by email for every charge.
6. Insurance, copays, and balances
If Practice bills Client’s health insurance on Client’s behalf, Client authorizes Practice to charge the Payment Method for any patient-responsibility amount the insurer assigns to Client, including (without limitation) copays, coinsurance, unmet deductibles, and amounts denied by the insurer after a claim has been filed in good faith. Practice will notify Client by email before processing any charge resulting from an insurance denial or post-adjudication balance, and Client will have seven (7) days to dispute the charge in writing before it is processed.
7. Revocation
Client may revoke this Authorization at any time by giving Practice written notice (email is acceptable) at {practice email}. Revocation takes effect on the next business day after Practice receives the notice and does not relieve Client of liability for charges already incurred (including fees for sessions already provided and late-cancellation or no-show fees triggered before the revocation).
8. Disputes and chargebacks
If Client believes a charge is in error, Client agrees to contact Practice first to attempt resolution before initiating a dispute or chargeback with the card issuer or bank. Practice will respond within five (5) business days. Charges that are later confirmed valid but reversed via chargeback may result in Practice declining to schedule further appointments and may be referred for collection at Practice’s discretion.
9. Term
This Authorization is effective as of the date Client signs below and continues until Client revokes it in writing (Section 7), Practice terminates the therapeutic relationship in writing, or Client’s account is closed for any other reason.
10. Acknowledgements
By signing below, Client acknowledges that Client:
- is the authorized cardholder or account holder for the Payment Method, or is acting with the cardholder’s or account holder’s consent;
- has received and read Practice’s fee schedule and cancellation policy;
- understands that this Authorization permits recurring charges under the conditions described above;
- has received a copy of this Authorization for Client’s records.