Automatic Credit Card Payment Authorization Form printable pdf download

Automatic Credit Card Payment Authorization Form

Do You Want to Leave a Confidential Credit Card on File?

There are many reasons to consider using an automatic credit card payment for co-

payments or deductibles, such as convenience if you are being seen when support staff

is not present to help with payment, to save time checking in each visit, to cover

copayments if you send your teen in for appointments without a parent, and to avoid

monthly administrative charges for unpaid balances left on your account. If you are

interested in keeping your confidential credit card information securely on file with us,

please complete this form. You may cancel this authorization at any time. If you prefer

not, simply return this form blank to the front desk. – Thank you.

Automatic Credit Card Payment Authorization Form

I, _______________________________________, agree to provide the following credit card

information and allow the credit card listed below to be automatically charged after each office

visit for copayments and/or outstanding account balances.

Credit Card Type:

American Express

Discover

Master Card

Visa

First name on credit card:

_________________________________

Last name on credit card:

_________________________________

Address listed with credit card:

_________________________________

Zip Code:

_________________________________

Credit Card Number:

_________________________________

Credit Card Exp. Date:

_________________________________

Security Code (3 or 4 digit):

_________________________________

(found on the back of the card or front of American Express)

This visit only

Long Term Payment Arrangements for Larger Balances

Future Co-pays and Balances Due

Patient Name:_________________________

Patient Acct #:________________________

Today’s Date: _______________________________

Signature:_______________________________________

For Admin Use Only:

Acct # ______________Doc ID _______

/autoccpaymentf

Rev. 3/13/12

Automatic Credit Card Payment Authorization Form

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