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Payment authorization

Agree to card-on-file terms. We do not collect card numbers on this form — those go only through a secure payment page when enabled.

By signing below, you authorize Psych Arts Services / Brown Psychiatric Services to charge a payment method you place on file (or provide for a visit) for services rendered and for sessions not cancelled at least 24 hours in advance, consistent with practice policy. Charges appear under a practice descriptor (e.g. Psych Arts Services). This authorization remains until you cancel it in writing. You agree to notify the practice of account changes. You certify you are an authorized user of the payment method and will not dispute transactions that match this authorization and the services or late-cancel fees described. Card numbers are not collected on this web form. When digital card vaulting is enabled, you will use a secure payment page; until then you may complete card details through a secure link or method the practice provides after booking.

Prefer a digital vault (no card number typed here): secure card setup.

I authorize the practice to charge the payment method I place on file for services and for late cancellations (less than 24 hours’ notice), as described above.I am an authorized user of that payment method and will keep the practice informed of changes.Type full legal name *

Draw your signature *

Draw with finger, mouse, or stylus. This is your electronic signature.

Date *Email for receipt / follow-up *

Submissions are emailed to the practice over encrypted mail for handoff. This site does not keep a clinical chart.