Payment Form

Sign and complete this form to authorize The Palms 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.

  • (ex. Deductible, medications, cash, cigarettes, payment plan, etc.)
  • American Express