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Cardholder Name

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Passenger Name

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Cardholder Email

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Cardholder Phone

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Card Number

Expiration

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CVC

The 3 digit (back) or 4 digit (front) value on your card.

Billing Address

Address Line 1

Address Line 2

City

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Signature

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Credit Card Authorization & Policy Agreement

By signing above, I acknowledge and agree to the following terms with NYC Wheelchair Transportation: 1. Electronic Signature Consent I understand that my electronic signature is legally binding and authorizes NYC Wheelchair Transportation to process charges according to the terms listed below. 2. Cardholder Authorization I am the authorized cardholder of the payment method provided. I authorize NYC Wheelchair Transportation to charge my card for scheduled transportation services and any additional charges described in this agreement. I agree not to dispute any charges that comply with these terms. 3. Accurate Trip Information I confirm that all trip details I provided—including pickup date, time, location, accessibility conditions, number of steps, passenger needs, and service type—are accurate. I understand that incorrect information may result in additional charges. 4. Cancellation Policy I understand and agree to the company’s official cancellation policy: 24-Hour Risk-Free Cancellation (For bookings made 7+ days in advance): Cancel within 24 hours of booking → 100% refund. Trips scheduled to occur within 24 hours of booking are not eligible for risk-free cancellation. General Cancellation Policy: Cancel more than 72 hours before pickup → 20% non-refundable. Cancel less than 72 hours before pickup → 50% non-refundable. Same-day cancellations or when the driver is en route/on site → 100% non-refundable. At the company’s discretion, I may apply 100% of my deposit as credit toward a future trip. Official Cancellation Procedure: All cancellations must be submitted using the official form: https://nycwheelchairtransportation.com/cancellation-survey-form/ Failure to submit this form may result in a 100% administration/transaction charge. 5. No-Show Policy If I do not cancel at least 24 hours before pickup, the trip is 100% non-refundable. If the driver arrives and the passenger is not present or reachable, the trip is treated as a No-Show and billed in full. I understand that No-Show charges are valid and not grounds for a credit card dispute. 6. Additional Charges I authorize charges for any additional costs required for my trip, including but not limited to: Tolls Parking fees Extra mileage Waiting time Step/Stairs Assist (including Two-Men Assist) Providing a wheelchair for temporary use Vehicle/service upgrades required for safety or medical need These charges may be applied after service is completed. 7. Incorrect or Incomplete Information I understand that I am responsible for providing accurate details regarding passenger needs, mobility limitations, number of steps, accessibility conditions, or required assistance. If the actual conditions differ from what I reported (e.g., more steps than stated, additional assistance required, blocked access, or unsafe conditions), I authorize NYC Wheelchair Transportation to apply all necessary additional charges, including additional step/stairs assist fees or extra wait time. I acknowledge that providing incorrect information does not exempt me from charges and does not constitute valid grounds for a dispute. 8. Trip Structure, One-Way Charges & Reservation Numbers I understand and agree that transportation services are billed per way, unless my written quote clearly states otherwise. Each direction of travel—outbound or return—is considered a separate reservation and receives its own unique reservation/confirmation number and its own corresponding charge. I acknowledge that this does not constitute duplicate billing. For standard trips, the quoted price applies to one way only, unless the quote includes “each way × 2” or clearly lists a combined round-trip price. For By-The-Hour reservations, if the quote shows “each way × 2,” this indicates that both directions of travel have been calculated and included along with the hourly rate. I agree that multiple charges for multiple ways of a trip are valid and authorized and do not constitute duplicate or erroneous charges. 9. Delay Policy for Ambulance, Ambulette & Wheelchair Taxi Services (Emergency Priority Law) I understand that delays may occur for reasons related to safety, medical necessity, or state-mandated emergency protocols. By New York State law, if an ambulance assigned to a non-emergency trip receives an emergency call, the crew is legally required to respond to the emergency first. This may delay my scheduled pickup. I acknowledge that such delays are lawful, unavoidable, and do not constitute service failure, refund eligibility, or valid grounds for a dispute. I also understand that Ambulette and Wheelchair Taxi drivers may experience delays if the prior passenger requires unexpected medical attention, safety assistance, or step-related support. Drivers and medical crews must remain with the current passenger until the situation is resolved. I acknowledge that these delays are part of responsible medical and mobility transportation operations and are not valid reasons to refuse payment, demand refunds, or file credit card disputes. 10. Charge Adjustments After Service I authorize NYC Wheelchair Transportation to charge any outstanding or adjusted amounts after the trip is completed (including additional miles, wait time, tolls, or required services discovered at pickup). 11. Refunds & Credits Refunds and credits are issued under the cancellation policy stated above. Bank processing times may vary. I agree not to dispute charges that fall within these agreed terms. 12. Customer Support For questions or concerns regarding charges, I agree to contact NYC Wheelchair Transportation directly before initiating any dispute: Phone: 212-705-8773 Email: [email protected] 13. Final Acceptance By signing above, I confirm that I have read, understand, and agree to this Credit Card Authorization & Policy Agreement, including all terms regarding cancellation, no-shows, additional charges, one-way pricing, emergency-related delays, and charge authorization. I authorize NYC Wheelchair Transportation to process all related charges accordingly.

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Credit Card Authorization Form

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