A - Applicant Information
Name *
Name
Client Information
If Recipient of Treatment or Evaluation is Different from Payee Please Provide the Following Information:
Client Name
Client Name
B - Billing Information
Please complete the following information if you have chosen to use credit/debit card method to pay for a co-payment or total cost of services
As it Appears on Credit / Debit Card
Mailing Address *
Mailing Address
Credit Card Authorization
Provider *
Card Expiration Date *
Card Expiration Date
Authorization
I authorize Dr. James D. Wellman Psy. D. or its authorized credit/debit card transaction agent(s) to bill my credit/debit card account indicated above for assessment, therapy or consultation.
Date *
Date