Common Contracts
1 similar Credit Card Authorization and Payment Agreement contracts
Hope Enrichment Center Credit Card Authorization and Payment Agreement FormCredit Card Authorization and Payment Agreement • August 18th, 2020
The Hope Enrichment Center (HEC) has implemented a policy which enables you to maintain your credit card information securely on file. In providing us with your credit card information, you are giving HEC permission to automatically charge your credit card on file for your co-pay, failed scheduled appointment fees ($50.00 per FSA), and any/all outstanding balances on your account [or any other patient(s) you have listed on this form] with HEC. By signing this agreement, you understand that 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.
