WELL MINDS COUNSELING, PLLCTana Carpita, MSW, LICSW2525 N. Arizona Biltmore Circle, Suite B220Phoenix, Arizona 85016(425) 588.9280 Please enable JavaScript in your browser to complete this form.I authorize Well Minds Counseling LLC, to charge the portion of my bill that is my financial responsibility to the following credit card:AmexVisaMastercardCredit Card NumberCVV CODE:Expiration Date:Cardholder Name (Print):Billing Address for the Credit Card:Credit Card Authorization AgreementI authorize Well Minds Counseling to charge my credit card per the below.I, the undersigned, authorize and the charge my credit card by Well Minds Counseling, LLC, as indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibility. This authorization relates to all payments not covered by my insurance company for services provided to me by Well Minds Counseling, LLC. This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 60 day notification to Well Minds Counseling, LLC in writing and the account must be in good standing. Your NameFirstLastToday's DateSubmit
