Authorization for Credit Card Use
Michael D. McGee, M.D.
Office: 805-459-8232 Cell: 978-360-6071
Fax: 877 399 5883
Board Certified, General Adult Psychiatry, Addiction Psychiatry and Psychosomatic Medicine
PO Box 545, Avila Beach, CA 93424-0545
COMPLETE THIS AUTHORIZATION and click “Submit” on the bottom of the form.
All information will remain confidential and protected.
Name on Card:
Credit Card Type:
Credit Card Number:
Card Identification Number:
I authorize WellMind LLC to charge the amounts listed in my Treatment Agreement for services provided to me during my treatment to the credit card provided herein. I agree to pay for these purchases in accordance with the issuing bank cardholder agreement.
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization for Credit Card Use
Agree & Sign