Common Contracts
1 similar Patient Credit Card on File Agreement contracts
Patient Credit Card on File AgreementPatient Credit Card on File Agreement • September 20th, 2021
We have implemented a policy which enables you to maintain your credit card information securely on file with Aura Endocrinology ( the “Practice”). In providing us with your credit card information, you are giving the Practice permission to automatically charge your credit card on file for your co-pays and any outstanding balance [or any other patient(s) you have listed on this form] at the time of service. By signing, you consent and authorize that this agreement will remain in effect until and unless you revoke this form at any time by submitting a written request to the office.
