Credit Card Authorization Form for Cancellation or No Show matters

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

 

    Credit Card Information

    LATE CANCELLATIONS FEE OF 50% OF THE SERVICE CHARGE IF I ONLY GAVE TOP REHAB MORE THAN 4 HOURS NOTICE BUT LESS THAN 24 HURS NOTICE TO CANCEL THE APPOINTMENT (BY EMAIL OR PHONE CALL OR VOCIE MESSAGE ANY OF THESE ACCEPTED METHODS.)

    LATE CANCELLATIONS FEE OF 100% OF THE SERVICE CHARGE IF I ONLY GAVE TOP REHAB 4 HOURS OR LESS NOTICE TO CANCEL MY APPOINTMENT (BY PHONE CALL OR VOCIE MESSAGE AS THE ACCEPTED METHODS.)

    OR FEE OF 100% OF THE SERVICE CHARGE FOR LAST MINUTE ONSITE CANCELLATION OR REDUCTION OF THE SERVICE LENGTH DUE TO MY LATENESS FOR AN SCHEDULED APPOINTMENT OR MY INSURANCE PLAN’S DIRECT BILL ISSUES

    OR NO SHOW FEE OF 100% OF THE SERVICE CHARGE

    I understand that my information will be saved to file for future transactions on my account and I will not dispute such charge if it occurs by providing the signature below.