William G. Austin, Ph.D.
(970) 846-1157 voice
(303) 217-8990 fax
Mail: P.O. Box 3939
Evergreen, CO 80437
Northwest Colorado Psychological Services 710 Kipling St.
737 Lincoln Ave., 2nd Floor Ste. 306
Steamboat Springs, CO 80487 Lakewood, CO 80215
Information is absolutely confidential and in accordance with Colorado Revised Statutes, mental health licensing act. (C.R.S. § 12-43-218).
We do not sell, trade, or otherwise transfer to outside parties your personally identifiable information. This does not include trusted third parties who assist us in operating our website, conducting our business, or servicing you so long as those parties agree to keep this information confidential. We may also release your information when we believe release is appropriate to comply with the law, or protect ours or others rights, property or safety.
Your credit card will be charged when you make your pre-payment. Cancellation of appointments must be made 48 hours in advance. If that occurs your credit card will be refunded.
Accepted Payment Methods: Visa, Master Card, American Express, Check/Money Order
CREDIT CARD BILLING FORM
[Fax or e-mail to Dr. Austin]
Down load Credit Card Form for Colorado
Name on Card: _________________________________________
Type of Card
Card Number: ____________________________________
SVG Code (back of card): ____________
Phone Number associated with card: _________________________________
I authorize Dr. William G. Austin to charge my credit card for psychological services rendered [type initials]
Signature (if faxing):