Credit Card Authorization – Help with Solutions

Credit card authorization & AutoPay form

Thank you for choosing Solutions Counseling. Please enter your credit card information into our secure form below. Contact Customer Service at 763-515-4563 or questions@helpwithsolutions.com with any questions:

Client Name(Required)

First Last

Client ID (if available)

Name on Credit Card(Required)

First Last

Name of Person Completing this Form(Required)

First Last

Credit Card Information(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Credit Card Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Enter Email

Card-On-File Consent(Required)

I have read, understood, and agree to the information below:

I authorize Solutions Counseling to use the credit card provided towards any outstanding balance on this account when you have notified me verbally or by email of your intent to do so. I understand that this includes, but is not limited to: copays, coinsurance, no-show fees, and approved payment plans. I further understand and agree that no notification of payment will be provided in advance when I am using Auto-Pay (see Auto-Pay Consent) or have past due balances. You have my consent to use the card on file to pay any past due balances (more than 30+ days) in full and without notice. I certify that I am an authorized user of this credit card/bank account and will not dispute these transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form. I agree to notify Solutions Counseling Service in writing of any changes in my account information or upon termination of this agreement.

Auto-Pay Consent (Optional)

I consent to pay statements using Auto-Pay and agree to the terms below:

I authorize the credit card provided above to be processed on the 15th of the month or the first business day after for the most recent statement balance of the client listed in this form.

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