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 Legal Name *

Your Provider *

Contact Name *

Relationship to Client *

Contact Phone Number *

Numbers only, DO NOT accept any symbol

Contact Email Address *

We accept credit card VISA, MASTER and DISCOVER only.

Cardholder’s Name *

Address *

Address

City

State/Province

Zip/Postal

Country

Credit Card Number *

Credit Card Type *

We accept credit card VISA, MASTER and DISCOVER only.

Card Expiration (MMYY) *

Only allow 4 digital date (Month and Year) format as MMYY, Numbers only, DO NOT accept any symbol

Security Code *

Additional request: *

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 *

If you are human, leave this field blank.