Credit Card Authorization First Name(Required)Last Name(Required)Phone(Required)Email(Required)CREDIT CARD AUTHORIZATION FORMThe credit card information below is provided to Neighborhood Counseling Center (NCC) for payment of copayment, deductible, co-insurance, or self-pay charges. Credit card will be charged when a service is rendered by an NCC provider. You may remove this information at any time by contacting the Billing Department at (718) 837-4190. *Please inform the billing department if you wish to make a change to payment method in the future.Authorized Cardholder Name (as shown on card)(Required)Card Type(Required) Mastercard Visa American Express Discover Card number(Required)Expiry Date (month/year)(Required)Billing Zip Code(Required)CVV Code(Required)I authorized user of this credit card, authorize Neighborhood Counseling Center to charge this credit card for services as agreed above. I agree to pay Neighborhood Counseling Center for services rendered to me or my dependents. I understand that my information will be saved for future transactions on my/my dependents accounts. I can withdraw this authorization by contacting the Billing Department (718) 837-4190 or 7701 13th Avenue, Brooklyn, NY 11228Full Name (electronically signed):(Required)Date(Required) Δ
