Secure Payment Form – Banyan Detox Stuart

Sign and complete this form to authorize Banyan Treatment & Recovery to make a one-time debit to your credit card listed below. By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account.

Full Name (Person completing the form)*
First Last
Client's Name*
First Last
Payment Amount*
Reason for Payment*
- Private Pay (Non Insurance Treatment)
- Deductible/Copay/Out of Pocket
- Airfare Reimbursement
- Incidentals (cigarette’s, clothes, supplies, personal needs etc)
- IOP Rent
- Pay to Member (Policy Reimbursement)
- Housing Fee
- Family Week
Memo / Notes
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State ZIP Code
Email*
Authorization*
- I authorize Banyan Treatment Center to charge my credit card account indicated below for the total amount given above on or after the specified date. The payment is for the above described goods/services for the client that is named above.
Total Amount
$0.00