Common Contracts
1 similar Patient Credit Card on File Agreement contracts
PATIENT CREDIT CARD ON FILE AGREEMENTPatient Credit Card on File Agreement • August 28th, 2020
We have 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 Alexandria Associates In Dermatology 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 the 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.
