This clear, compliant Payment Authorization Form allows healthcare providers to securely collect and store patient payment details for ongoing services, product purchases, or cancellation fees. Designed for licensed medical, aesthetic, and wellness practices, it includes fields for credit cards, HSA/FSA, CareCredit, billing address, and cardholder signature. It outlines terms for recurring charges, late cancellations, and no-shows—supporting seamless billing and financial transparency.

Download now to streamline your checkout process, reduce missed payments, and maintain a professional, HIPAA-conscious billing experience.