Spencer Psychology

Authorization for Credit Card Vault

I authorize Spencer Psychology to place my credit card number with an encrypted credit card processing service “vault.” Card numbers are not visible to any staff member once placed in the vault. I authorize Spencer Psychology to use the card for outstanding balances on my/my authorized user’s account for services, no shows and late cancelations.

 I understand that no shows/cancelation fees may not be eligible for payment by a health savings plan, but if used for these fees anyway, the card holder may have to reimburse the HSA account if audited. Spencer Psychology will not know if a vaulted card is for an HSA account, and we are not liable for users not following their HSA plan requirements, or for users not following guidance given by the card holder.

Due to privacy regulations, Spencer Psychology may not discuss with the card holder any clinical information for the adult client, nor arrangements made with the client about choice of session type, no show/late cancelation fees, or waivers of insurance. These issues will be explained to the client, and it is the client’s responsibility to discuss this with the card holder.

The card holder may withdraw permission for card use at any time, with written notice to Spencer Psychology. Refunds cannot be made retroactively from the receipt of the written notice of cancelation

Client Name:  

Electronic Signature of Client/Parent/Guardian: