1258 High Street, Eugene, OR 97401
Phone 541-342-8437 | Fax 541-242-2999
Automatic Payment Authorization Form
Client Name: Date of Birth:
Payer, if different than client:
Billing Address:
City, State, Zip:
Phone Number: Email Address:
Payment Information:
Cardholder Name:
Card Number:
Expiration Date (MM/YY):
CVV:
Billing ZIP Code:
I authorize Center for Family Development to automatically charge the card listed above for:
- Monthly outstanding balances
- Recurring service fees
- Approved invoices due under our service agreement
I certify that I am an authorized user of this payment method and will not dispute authorized
recurring charges.
Authorization Terms
- Charges will vary based on the balance due each month.
- I will receive invoices/statements prior to processing when applicable.
- Charges will be processed on or after the 25th day of each month.
- This authorization will remain in effect until canceled in writing.
- I may revoke this authorization by providing written notice at least five (5) business days before the next scheduled payment.
- Returned payments, declined transactions, or chargebacks may result in additional fees or
suspension of services.
By signing this form, I acknowledge and agree to the authorization terms listed above.
This document is being signed by:
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relation to client:
Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
