Credit Card Authorization

I authorize Fusion Family Consulting to charge the portion of my bill that is my financial responsibility to the following credit or debit card:

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I, the undersigned, authorize and request Fusion Family Consulting to charge my credit card, indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibility.

This authorization relates to all payments not covered by my insurance company for services provided to me by Fusion Family Consulting. This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 60 day notification to Fusion Family Consulting in writing and the account must be in good standing.