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.
Patient Credit Card on File AgreementPatient Credit Card on File Agreement • June 18th, 2020
We have implemented a policy which enables you to maintain your credit card information securely on file with Mahoney Dermatology Specialists. In providing us with your credit card information, you are giving Mahoney Dermatology Specialists 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.
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.
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.
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.
Patient Credit Card on File AgreementPatient Credit Card on File Agreement • February 15th, 2022
We have implemented a policy which enables you to maintain your credit card information securely on file with Lea H. Kirkland, MD, PA. In providing us with your credit card information, you are giving Lea H. Kirkland, MD, PA permission to automatically charge your credit card on file for your Office Visit [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.
