Credit Card on File Policy Credit Card on File Policy Tender Rock Counseling requires that you provide a credit card on file with our office. Credit Cards on file will be used to pay account balances: Credit cards will be charged at the time of service for your patient responsibility. Out-of-network insurances will be charged the full rate (see first paragraph under “TRC Fee Policies” in Fee Agreement) at time of service. Your account will be credited and adjusted if insurance reimburses our office. If your card expires or becomes uncollectible, we will request you to provide an updated Credit Card. Ultimately, you are responsible for knowing what services are covered by your insurance company, how often, and how much of the cost is your responsibility. You will be responsible for any portion of services that your insurance does not cover. Credit Card on File Authorization: I agree to place my credit card on file and authorize TRC staff to run my credit card for the purposes stated above. Client Information Client Legal Name * Your Provider * Mark (Shin-Lu) LiuJennifer LiuUnknown Contact Name * Relationship to Client * Contact Phone Number * Numbers only, DO NOT accept any symbol Contact Email Address * Credit Card Information We accept credit card VISA, MASTER and DISCOVER only. Cardholder’s Name * Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Credit Card Number * Credit Card Type * VISAMASTERDISCOVER We accept credit card VISA, MASTER and DISCOVER only. Card Expiration (MMYY) * Only allow 4 digital Month and Year format as MMYY, Numbers only, DO NOT accept any symbol Security Code * Acknowledgement Information Additional request: * Request to replace the existing Credit Card information on file with this one.N/A By checking this box I certify * I agree to place my credit card on file and authorize TRC staff to run my credit card for the purposes stated above. Signature of Adult Client / Parent / Legal Guardian * By typing your name to agree this "Credit Card On File Policy".