Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.

• BY SUBMITTING THIS FORM  I AM AUTHORIZING PATHWAYS NEUROPSYCHOLOGY ASSOCIATES TO CHARGE MY CREDIT CARD ABOVE FOR AGREED UPON PATIENT RESPONSIBILITIES. I UNDERSTAND THAT MY INFORMATION WILL BE SAVED TO MY SECURE PATIENT ACCOUNT FOR FUTURE TRANSACTIONS ON MY ACCOUNT.