Credit Card Authorization Form - Family Planning Associates Chicago
ADVERTISEMENT
1FAMILY PLANNING ASSOCIATES MEDICAL GROUP, LTD
5086 North Elston Ave, Chicago, IL 60630
773-725-0200
659 West Washington Blvd, Chicago, IL 60661
312-707-8988
7845 South Cottage Grove Ave, Chicago, IL 60619
773-892-0102
Credit Card Authorization Form
FOR USE ONLY ON BALANCE DUE ACCOUNTS
Patient Information
Patient Name: __________________________________________________________________________________________
Credit Card Holder's Name:
_____________________________________________________________________________
(as it appears on the card)
Credit Card Holder's Address: ________________________________________
_________________________________________
Phone Number:
(______)________‐_______________
Payment Information
Type of Credit Card:
____ Visa
____ MasterCard
____ Discover
16 Digit Card Number: ______________________________________________
Expiration Date: (___/_______)
3 Digit Security Code: ___________ (on back of card)
Payment Information
$
_________.___
____ One‐Time Charge
____ Monthly
____Weekly
I authorize Family Planning Associates Medical Group, Ltd (FPA) to charge my personal credit card listed for the amount
authorized above for the balance due on my account. I agree to pay the amount which has been explained above. I
understand that Family Planning Associates Medical Group will not process this payment until this original form is signed and a
copy of my picture ID is received by our facility.
Signature: ___________________________________________________
Date: ____/_____/________
Please mail this completed form to:
Family Planning Associates Medical Group
5086 N. Elston Ave
Chicago, IL 60630
Attn: Patient Accounts
____
I request for Family Planning Associates Medical Group to mail my receipt(s) to my billing address when my
balance is zero.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business