Credit Card Authorization

If agreed upon by myself and Launchfit™, I hereby give permission to charge my credit card for the total amount upon receipt of insurance payments that have been sent to me, in my name, directly from Blue Cross Blue Shield. I understand and agree that this payment is to go directly to Launchfit™ and my provider in its entirety for services rendered. I can also choose to bring in the checks and endorse them over directly or deposit the checks and pay by personal check. In any instance, my credit card information must stay on file in the case of non-payment by me.

Launchfit™ will make every reasonable effort to contact me prior to my card being charged, making sure this is the form of payment I would like to us and I will be given a receipt of payment. If the total invoice is not paid within a 10 day grace period I give permission for my card to be charged the entire amount of the insurance checks that were sent to me.

** Please Note: Charge will be listed on credit card statement as New York Chiropractic Services