Credit Card / Debit Card Authorization Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Date Exp. Layout RECURRING CHARGE – I authorize regularly scheduled charges to my credit card or bank account. I understand I will be charged the amount indicated on my patient statement each billing period. A receipt for each payment will be provided to me and the charge will appear on my credit card or bank statement. I agree that no prior notification will be provided unless the date or amount changes, in which case I will receive notice from BBTC at least 10 days prior to the payment being collected. I authorize Building Bridges Through Communication to charge my Credit Card or Bank Account below for the statement amount indicated on the patient statement one week following receipt of the patient statement. Authorize Charge to CC or DC *YESNOThis Payment is for *(Description of Goods/Services payment is for) Billing Information Billing Address *Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Credit Card Information *VisaMasterCardAmexDiscoverCardholder's Name *FirstLastAccount Number *Exp. Date *CVV *Authorized Signature * Clear Signature Date *Printed Name *FirstLastSubmit
