Payment is due within thirty (30) days from the statement billing date. If payment is not received, you authorize ElderConsult Geriatric Medicine to charge the balance due to the credit card linked to your file. If payment is not received within 60 days, there will be a 5% penalty applied to the outstanding balance every 30 days, until paid in full or other arrangements are made with ElderConsult Geriatric Medicine.
My signature below confirms receipt of the above billing fees, my agreement to pay for all services rendered, in accordance with the terms and conditions set forth in the ElderConsult Services Agreement, and my authorization to charge my credit card (card info will be stored securely) upon my notification by telephone/email and/or in the event payment has not been received when due, as explained above.