Credit Card on File Authorization Form

Eden Park's EasyPay

Authorization Form
Cardholder Name*

First NameLast Name
I authorize Eden Park Pediatric Associates to keep my credit card on file in a secure system. I authorize Eden Park to charge my unpaid co-payment and/or 60-day + overdue balances under $200 to the credit card listed below to avoid $20 missed co-payment fee and overdue balance fees. Eden Park Pediatrics will contact me directly for any balance over $200. This card will not be used without my authorization during office visits. If my card is charged for the agreed terms I will receive a emailed receipt. If payment collection is attempted and there are insufficient funds, a billing specialist will reach out to discuss payment options.

This authorization will remain in force on each of my children’s accounts until they are no longer patients of Eden Park Pediatric Associates or until a written request by the cardholder instructing the practice to remove the authorization.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Date of Authorization*

MonthDayYear
Date
Cardholder Signature*

Powered by Jotform SignClear
Cardholder email for payment receipts*
example@example.com

Credit Card Registration*

Credit Card RegistrationOne time reversible set up charge

$0.01

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Full financial policy may be viewed at https://www.edenparkpeds.com/About-Us/Office-Policies/Financial-Policy
Should be Empty:

Eden Park's EasyPay