Card on File Agreement

Patient First Name

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Patient Last Name

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I hereby authorize Stepping Stones Psychiatric Care to charge my credit/debit card( ending ) for any amount not covered by insurance or self-pay, for all services related to the appointments.

My credit card will be stored by Icanotes.ehr to secure the web based medical records. The credit card by the accredited bank with Stepping Stones Psychiatric Care to collect payments.

I will receive a receipt detailing the amount charged by email or text.

I may cancel my agreement anytime by contacting Stepping Stones Psychiatric Care; any unpaid amounts to any appointments not covered by insurance / Self Pay will be billed to me directly.

Please indicate one option:

Yes, I agree to the agreement for services rendered

No, I will not agree to put my credit card on file

Signature:

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Date:

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