Credit Card Authorization Form

For most of our patients, the majority of our services are low cost or free if they are deemed unable to cover the costs. However, to combat the non-compliance issue we have in the mental health care field, we require credit card information up front. A $50 fee will be charged if the patient does not cancel or show up. The patient must cancel or reschedule within 24 hours.

Credit card number

Please fill out this field.

Expiration Date

CVV

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Zip Code

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Cardholder Name

Please fill out this field.

I authorize National Alliance for Mental Health & Substance Abuse Recovery to run my card and agree to the terms and conditions.

Yes, I consent and understand the terms and conditions.

No, I understand by non-consenting, I forfeit my right to receive care from NAMHSAR