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Credit Card Authorization form

Credit Card Authorization form

Your SimplePractice account includes several default consent document templates, such as the Credit Card Authorization form. You can locate these consent documents in Settings > Client Portal > Shared Documents and Files. For more information, see: Using consent documents and intake forms.

If you accidentally deleted or saved over this form and would like to revert back to the default text, you can find this below:

In this guide, we’ll also cover:

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.

Credit Card Authorization

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 CANCELLATION POLICY: I also agree that my credit card can be charged for any session that is not cancelled 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 know

  • The default consent documents included in your account will vary depending on your specialty and the date your account was created. You can add a new document, or edit an existing one, at any time by navigating to Settings > Client Portal > Shared Documents and Files
  • 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.
  • You can locate your statement descriptor at Settings > Billing & Services > Online Payments. For more information, see: Online Payments FAQs.

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