Serenity Wellness & Family Practice Authorization & Card on File Agreement

I, the undersigned cardholder, authorize Serenity Wellness and Family Practice to keep my credit card securely on file for future payments.

I understand and agree to the following:

My credit card information will be stored securely in compliance with PCI and HIPAA standards.

My card will not be charged without my prior knowledge and consent for each transaction, except for: no-show or late cancellation fees.
Outstanding patient balances that I have been notified about and agreed to resolve.
I am responsible for providing updated payment information if my card details change.

This authorization remains in effect until I provide written notice to revoke it.

I certify that I am the authorized user of this credit card and will not dispute payments that correspond to services or fees I have approved.

Last update 4/16/2026 by Serenity Wellness and Family Practice.