ABA of North Texas

Credit Card Authorization Form

Our office requires that a credit card be kept on file for payment of any co-payment, co-insurance, deductible, or charge that may not be covered by your health insurance. This form will be kept confidential and only authorized staff have access to the information.

Front of Credit Card
Accepted file types: jpg, jpeg, png, gif.
Back of Credit Card
Accepted file types: jpg, jpeg, png, gif.
MM slash DD slash YYYY

I acknowledge and authorize ABA of North Texas, LLC to charge the above credit card account for any co-payment, co-insurance, deductible and/or charges not covered by my health insurance provider. I acknowledge that my card will be run in the event payment is not received within thirty days after I receive a statement. I agree to receive billing statements, invoices and receipts via the email I have provided to this office. I agree to update any information regarding this credit card account.