[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-290046-105":53,"doc-detail-290046-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","electronic-payment-authorization-form-for-square-reader-download","Electronic Payment Authorization Form - For SQUARE reader - Download","","Electronic Payment Authorization Form for a SQUARE reader authorizes the Cardholder to pay Dr. Shawna Freshwater / Neuropsychological Institute, P.A. / Spacious Therapy. It sets charges for 45-minute therapy appointments and additional add-on intervals, and allows automatic future billing for scheduled appointments and unpaid invoices. The authorization remains active until withdrawn in writing, requires notice if card details change, and confirms agreement to professional and psychological services terms, cancellation/no-show fees, dispute resolution, and the Notice of Privacy Practices. It requests patient and cardholder details, last four digits, expiration date, full address, signature, and date.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/electronic-payment-authorization-form-for-square-reader-download/290046/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/electronic-payment-authorization-form-for-square-reader-download/290046.png","ImageObject",442,249,{"name":88,"@type":89},"Blitz","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does the Cardholder authorization allow Dr. Shawna Freshwater to do?","Question",{"text":108,"@type":109},"It allows Dr. Shawna Freshwater to charge the stored credit card automatically for future payments for scheduled appointments and for any unpaid invoices with the patient.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How are therapy appointment and add-on fees calculated?",{"text":113,"@type":109},"The form states $200.00 for each 45-minute therapy appointment, plus an additional $50.00 for each 15-minute add-on time increment.",{"name":115,"@type":106,"acceptedAnswer":116},"When does the authorization end and how can it be withdrawn?",{"text":117,"@type":109},"It remains in force until withdrawn in writing by the cardholder, and the cardholder must notify Dr. Freshwater of updated card information if the card expires or becomes invalid.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},290046,1790202420,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},24464137899374,"https://us-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","NeuroPsychological Institute, P.A.  \nShawna Freshwater, Ph.D.  \n[SpaciousTherapy.com](SpaciousTherapy.com)  \nElectronic Payment Authorization Form  \nFor SQUARE reader  \nI,  (“Cardholder”) agree to pay Dr. Shawna Freshwater/ Neuropsychological Institute, P.A / Spacious Therapy  \n$200.00 for each 45-minute therapy appointment, and an additional $50.00 for each add-on time interval of 15-minute increments with   (“patient”), the frequency of which will be determined by Dr. Freshwater and patient.  \nCardholder has previously made at least one payment through SQUARE reader and selected the option to store credit card number (referenced below) to be used for future payments. Cardholder authorizes Dr. Shawna Freshwater to charge this credit card automatically for all future payments for scheduled appointments with patient and for any unpaid invoices with patient. This authorization does not release or modify patient’s obligation to pay all outstanding amounts $ due, or prevent from accepting or requiring other forms of payment. This authorization shall remain in force until withdrawn in writing by cardholder. Cardholder agrees to notify Dr. Freshwater of update credit card information upon request if credit card expires or is invalid. Cardholder has read, understands, and agrees to be bound by all of the terms of Agreement for Professional Services, or Psychological Services between Dr. Shawna Freshwater and Patient, including the provisions regarding billing and payments, appointment cancellation and no show fees, and dispute resolution. Cardholder has also read and understands Dr. Shawna Freshwater’s Notice of Privacy Practices.  \nPatient Name:  Patient signature  Credit/Debit Card Information to be stored in SQUARE:  \nLAST FOUR DIGITS OF CREDIT CARD Number:   \nExpiration Date: /   \nCard Holder Information:  \nPlease indicate the name and complete address associated with this debit or credit card you wish to use for payment via SQUARE services. Name:   \nAddress:   \nCity:  State Zip Code   \nSignature of Authorized card holder:  \n__________________________________________________  \nDate:","cbCairLdcHja7o3n","https://ap.wps.com/l/cbCairLdcHja7o3n","pdf",50194,"English","# Electronic Payment Authorization Form\n## Parties and pricing\n## Authorization scope and duration\n## Card and cardholder information\n## Signature and date","[{\"question\":\"What does the Cardholder authorization allow Dr. Shawna Freshwater to do?\",\"answer\":\"It allows Dr. Shawna Freshwater to charge the stored credit card automatically for future payments for scheduled appointments and for any unpaid invoices with the patient.\"},{\"question\":\"How are therapy appointment and add-on fees calculated?\",\"answer\":\"The form states $200.00 for each 45-minute therapy appointment, plus an additional $50.00 for each 15-minute add-on time increment.\"},{\"question\":\"When does the authorization end and how can it be withdrawn?\",\"answer\":\"It remains in force until withdrawn in writing by the cardholder, and the cardholder must notify Dr. Freshwater of updated card information if the card expires or becomes invalid.\"}]","Electronic Payment Authorization Form - For SQUARE reader - Download | PDF",1789640141]