Credit Card Authorization Form

/Credit Card Authorization Form
Credit Card Authorization Form

Below you will find the link to the Kaplan Center’s credit card authorization form.

This form must be filled out to authorize charges such as the Quarterly Administrative Fee, virtual payments for office visits, or claim filing fees.

Should you have any questions about this form or the charges referenced above, please call 703-532-4892.

Click here to access the Credit Card Authorization Form.

Please return the completed form and bring it to your next appointment. You can also submit it in advance using one of the following methods:

  • Fax: 703-237-3105
  • Patient portal: If you have a patient portal account and a scanner, this form can be scanned and sent to us via the patient portal.
  • U.S. Mail: Attn: Jaclyn, Kaplan Center for Integrative Medicine, 6829 Elm St., Suite 300, McLean, VA 22101

IMPORTANT: Do not email this document back to us as it is not a secure method of communication.