IRIS HEALING® RETREAT
Credit Card Authorization Form

Card Type
Please Check One
Untitled*
- VISA®
- American Express®
- MasterCard®
- Discover®Card
Billing Information
Cardholder Name:*
Billing Address*
City*
State*
Zip*
Credit Card Information
Credit Card Number*
CVV*
Expiration Date
Client Info
Client Name*
Date of Birth:*
MM slash DD slash YYYY
Consent*
I authorize Iris Healing® Retreat, LLC to charge my credit card listed below for:*
Consent*
Check in this box to authorize pharmacy co-pays to be charged to the card below*
Consent*
Check this box to approve ancillary expenses to be charged to the card below. This includes transportation to/from the facility ,cigarettes , and any other elective purchases. If you would like to set a limit on how much can be spent on ancillary charges please enter that amount on the line below*
Ancillary spending limit:*
In the event you wish to change the credit card authorized herein to be charged, Iris Healing® Retreat requires notice of the desired change in writing, dated, and including the language set forth herein and all necessary card information, as well as the date on which the desired change shall be effective, and the cardholder’s signature. Cardholder agrees to update Iris Healing® Retreat with a new authorization prior to the expiration date of the card authorized herein to be charged, in order to ensure payments may be charged prior to services being rendered. I have the right to change or terminate this authorization at any time but must do so in writing via email to Info@IrisHealingRetreat.com The termination of this authorization shall be effective 24 hours after we receive the termination notice.

I, the undersigned, understand that all financial payments are considered final sale and are non-refundable.
Statement Email Address*
Cardholder Signature*
Contact Name*
Phone Number*
Date*
MM slash DD slash YYYY

VERIFY YOUR INSURANCE, NO COMMITMENT REQUIRED

At Iris Healing®, we offer a free and confidential verification of benefits with no commitment required. For our in-network insurance partners, Iris Healing® accepts PPO, EPO, and HMO plans. For out-of-network insurance, we accept most PPO policies. We are happy to answer any questions you have related to insurance coverage for mental health and addiction treatment.

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Call Us Today: (844) 663-4747

Rehab in Los Angeles You Can Trust

Licensed by the State Department of Health Care Services.

Iris Healing Center
Certification: 190056AP
Expiration Date: 12/31/2025

Iris Healing Retreat
License Number: 190943AP
Expiration Date: 1/31/2025

IRIS HEALING® RETREAT

Detox/ Residential

23033 OSTRONIC DR,
WOODLAND HILLS CA 91367

IRIS HEALING® CENTER

Outpatient

20300 VENTURA BLVD STE 300
WOODLAND HILLS CA 91364

IRIS TMS WELLNESS

20300 VENTURA BLVD STE 220
WOODLAND HILLS CA 91364

IRIS NEUROFEEDBACK

20300 VENTURA BLVD STE 275
WOODLAND HILLS CA 91364

Call Us Today: (844) 663-4747

Holistic Treatment You Can Trust

Licensed by the State Department of Health Care Services.

Iris Healing Center
Certification: 190056AP
Expiration Date: 12/31/2025

Iris Healing Retreat
License Number: 190943AP
Expiration Date: 1/31/2025

IRIS HEALING® RETREAT

Detox/ Residential

23033 OSTRONIC DR,
WOODLAND HILLS CA 91367

IRIS HEALING® CENTER

Outpatient

20300 VENTURA BLVD STE 300
WOODLAND HILLS CA 91364

IRIS TMS WELLNESS

20300 VENTURA BLVD STE 220 WOODLAND HILLS CA 91364

IRIS NEUROFEEDBACK

20300 VENTURA BLVD STE 275 WOODLAND HILLS CA 91364

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