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Authorization & Agreement Form

How It Works

Make charges in 3 easy steps

1. Have your client sign the completed Patient Payment Consent Form, or Client Payment Consent Form. Keep the signed form in your records.
2. Log on to ProfessionalCharges.com Website. Go to the secure Submit Charges Here page. Complete the form by identifying yourself and  entering the amount charged, card information and cardholder's identifying information. Click on the Submit Charges Now button to make the charge. 
3. Give your client a receipt.
   
   If you provide professional services over the internet or telephone, your clients can make the payment. Give your clients your license number. Instruct them to log on to ProfessionalCharges.com and click on the "Make a Payment" button and complete the payment form.
    
   If you have a Website with online registration for your services, you could have a Link to our online Submit Payment page open in a new window on your Website. Your clients could then make a payment without leaving your Site.

It is even easier to receive payment

Within seconds the client's card will be verified and charged, and a message will be sent to your screen indicating the acceptance or  rejection of the charge.

Post the payments easily in your billing or accounting program using your familiar posting method.

Six to seven business days after you have made the charge, the funds will be deposited directly into your bank account by electronic transfer.

You can check the status of any charges you submit and a summary of  your account at any time by clicking on the Account History button.

To Become a Member

You must be a professional, practicing in the United States.

Read the Membership Agreement, complete and submit the registration form indicating your acceptance of the terms. Then send us a copy of your professional license, the signed Authorization and Agreement Form  enabling us to transfer the payments directly into your bank account and to withdraw the initial $150 membership fee, and a voided check for that account.

We will notify you by e-mail that your account is active, and you will be able to start enjoying the benefits of accepting ATM, debit, check and credit card payments for your services.