Common Contracts
1 similar Patient Credit Card on File Agreement contracts
Patient Credit Card on File AgreementPatient Credit Card on File Agreement • December 3rd, 2013
We have implemented a policy which enables you to maintain your credit card information securely on file with ______________________. In providing us with your credit card information, you are giving ________________ permission to automatically charge your credit card on file for your co-pay [or any other patient(s) you have listed on this form] at time of service. By signing this you authorize this agreement will remain in effect until the expiration of the credit card account and that you may revoke this form at any time by submitting a written request.
