Northstar Orthodontics, INC. Auto Pay Authorization

Statement of Intent:

“My signature below authorizes NorthStar Orthodontics, Inc. to automatically charge my most recent monthly statement balance to the credit card I provide. NorthStar will send me a statement with a postmark of no later than the 3rd of each month and I will review it for accuracy. If I do not have any questions, the credit card charge will be submitted on or after the 10th of the month.”
Name on Card*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
NorthStar Account #(s)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit card information:

For your privacy and security, you may supply your credit card information to us in whatever manner you
choose. Please include the credit card number, expiration date, and 3 or 4 digit security code.
My credit card details will be:*

Phoned in to 800-346-0011 (Suggested method)Faxed to 800-346-0011Mailed to address below
NorthStar Orthodontics, Inc.

Attn: Accounts Receivable

PO Box 146

Park Rapids, MN 56470
Title
Signature*
Date*

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Date
Should be Empty: