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Credit Card Authorization form

Credit Card Authorization form

Your SimplePractice account includes several default consent document templates, including the Credit Card Authorization form. You can view, add or edit these consent documents at Settings > Client Portal > Shared Documents and Files.

For more information on consent forms, see Using consent documents and intake forms.

Important: While these templates are a great starting point for creating your own practice documents, be sure to review and tailor these to reflect your state’s legal requirements and the way you choose to run your practice. We recommend consulting your regulatory body if you have questions.

Original copy for the Credit Card Authorization form

You can find the default copy for this form below:

By your electronic signature of this form, you authorize charges to your credit card through Stripe via SimplePractice for services rendered. These charges will appear on your bank/credit card statement as [STATEMENT DESCRIPTOR]. You have the right to request a paper copy of this document.

I authorize [BUSINESS NAME] to charge my credit card through Stripe. [OPTIONAL CANCELATION POLICY: I also agree that my credit card can be charged for any session that is not canceled at least 48 hours prior to the scheduled session.]

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify [BUSINESS NAME] in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

Important details to consider

When you update the Credit Card Authorization form, there are a few important details to keep in mind:

  • The Credit Card Authorization form doesn’t include a field for clients to enter their credit card details. We recommend using the Credit Card Information form to securely request a client’s credit card information.
    • While SimplePractice is HIPAA and PCI compliant, it’s important to note that your storing credit card information in your account outside of the Credit Card Information isn’t PCI compliant. If you have collected credit card data on any custom intake forms, we recommend that you delete these completed forms.
  • You can locate your statement descriptor at Settings > Billing & Services > Online Payments. For more information, see Online Payments FAQs.

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