Common Contracts
1 similar Patient Credit Card on File Agreement contracts
Patient Credit Card on File AgreementPatient Credit Card on File Agreement • April 5th, 2017
We have implemented a program which enables you to maintain your credit card information securely on file with California Coastal Dermatology, which will conveniently allow you to maintain outstanding balances in a hassle-free process. In providing us with your credit card information, you are giving California Coastal Dermatology permission to automatically charge your credit card on file for your open balances [or any other patient(s) you have listed on this form]. By signing this you authorize this agreement to remain in effect until the expiration of the credit card account provided. You may opt out of this service at any time by requesting to do so, in person, over the phone, or in writing to billing@cacoastalderm.com.
