o N O RT H - Quarry Lake

o S O U T H - Southwest Medical Village

www.S pecialt y Au s t in .c om

C R E D I T C A R D A U T H O R I Z AT I O N
Please complete the following information.

I, ________________________________________________________ , am authorizing Specialty Clinic of Austin to charge

(print name)

my credit card in the event that I fail to show for a scheduled appointment, or do not give notification of my inability to
attend a scheduled appointment (including Telepsychiatry) in advance. Please remember that all follow-up appointments need
to be canceled at least 24 in advance and all new patient appointments need to be canceled at least 48 business hours in
advance. Please note, reminder calls/texts/e-mails are a courtesy. You are responsible for your appointment whether your
reminder was received or not.

Furthermore, for outstanding payments of services rendered, I authorize Specialty Clinic of Austin to charge my credit card
for the full amount due. I will not dispute charges for visits I have received or that I have not canceled in advance.

I further authorize Specialty Clinic of Austin to disclose information about my attendance/cancellation to my credit card
company if I dispute a charge.

Expert Care
Card Type (check one): o Visa o MasterCard o Discover o HSA/ Flex Card

Card #:__________________________________________ Exp Date: ________________ CVC: __________________

Name as Printed on Card: _____________________________________________________________________________

Billing Address: ______________________________________________________________________________________

(Street, City, State & Zip)

Signature: _________________________________________________________ Date: ____________________________

(patient or financially responsible party)

Print Patient Name: __________________________________________________________________________________

This form will be securely stored in your clinical file and may be updated upon request at any time.

Please note, your credit card will not be charged unless the following conditions apply: no-show for a scheduled appointment,
cancellation of a new patient appointment less than 48 business hours in advance, cancellation of a follow up appointment
less than 24 hours in advance, or participation in treatment (e.g. appointment or Telepsychiatry) without payment rendered.

o I agree that my electronic signature on this application is binding and enforceable, as if I had signed a paper copy.

N O RT H 4 5 1 5 S e t o n C e n t e r P k w y • S t e 1 7 5 • A u s t i n T X 7 8 7 5 9 • 5 1 2 - 3 8 2 - 1 9 3 3 p h • 5 1 2 - 7 7 7 - 4 9 4 9 f x
SOUTH 5625 Eiger Road • Suite 215 • Austin TX 78735 • 512-610-7900 ph • 512-610-8901 fx