Card Submission | Counseling & Consulting Billing Associates

Today's Date*

Your Full Name*

First Last

Please enter your full name as it appears on the credit card.

Your Therapists's Name*

Please enter the name of the therapist you are seeing/for whom you are filling out this form.

Billing Address*

Street Address Address Line 2 City State ZIP Code

Please enter your billing address as it appears on the billing statement for the credit card.

Phone*

Please enter your phone number where you can be contacted regarding scheduling, billing, etc.

Email*

Enter Email Confirm Email

Please enter an email address where you can be contacted regarding scheduling, billing, etc.

Card Type*

Credit Card Number (Visa, Mastercard, Discover)*

Please enter your full 16-digit credit card number as it appears on the card.

Credit Card Number (American Express)*

Please enter your full 15-digit credit card number as it appears on the card.

Credit Card Expiration Date*

Please enter your credit card MM/YY expiration date.

CVV (3 Digit # on back of card for Visa, Mastercard, Discover)*

Please enter the credit card CVV (3 Digit # on back of card)

CVV (4-digit # on front of card for American Express)*

Please enter the credit card CVV (4-digit # on the front of your card).

Agreement*

I certify that the above information is accurate and that it is my own payment information.

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Submitting your card