Crdit/Debit Card Payment
Consent Form
|
 |
| Patient
Name ____________________________________________________ |
|
. |
Print Last
|
First
|
Middle Initial
|
|
|
|
Name
on Card if different ___________________________________________ |
|
.
|
| I
authorize
____________________________ and ProfessionalCharges.com |
| . |
Provider
Name
|
|
| to
charge my card for professional services as follows: |
|
Initial |
|
|
______ |
This visit only,
for the amount of $__________________. |
| . |
. |
|
______ |
All
visits in the next 12 months, beginning _____ /_____ /_____, |
| . |
not to
exceed $____________ total. |
| . |
|
|
______ |
Recurring
charges, date(s) of service _____ /_____ /_____ to |
| . |
_____
/_____ /_____,
not to exceed $____________, |
| . |
____
monthly, ____ semimonthly, ____ weekly, ____ per visit. |
| . |
|
|
______ |
to
charge my card for the balance of fees not paid by my
insurance company within 90 days, as indicated above. |
|
Type
of Card: VISA
MasterCard.Discover
Exp. Date ____________ |
| . |
| Card Number _______ -
_______ - _______ - _______ DVV Number ________ |
| . |
| Card
Holder's Billing Address for Monthly Card Statements |
| |
| ___________________________________________________________________ |
| Street |
City |
State |
Zip |
| . |
| Card
Holder Signature
____________________________ Date
____ /____ /____ |
|
|
|
Charges
will appear on your card statement as ProfessionalCharges.com
|
