Electronic Payment Authorization Form
Effective Date of Authorization
*
-
Month
-
Day
Year
Date
Full Name of Patient
*
First Name
Last Name
Type of authorization:
*
New Authorization
Change Payment Amount
Change Payment Date
Change Banking Information
Discontinue Electronic Payment
Name
*
First Name
Last Name
Phone
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Down Payment Date for Withdrawl:
-
Month
-
Day
Year
Date
Amount for Down Payment: $
Date for Monthly Withdrawal: (please select one)
1st
4th
10th
15th
25th
Date of First Payment
-
Month
-
Day
Year
Date
Date of Last Payment
-
Month
-
Day
Year
Date
Amount for Monthly Payment: $
Amount of Last Payment: $
Total Number of Payments:
Please debit from my
Savings Account (contact your financial institution for Routing #)
Checking Account (staple a voided check below)
Routing Number: (valid routing # must start with 0,1, 2, or 3)
Account Number:
I authorize the above practice to process debit entries to my account. I understand that this authority will remain in effect until I provide reasonable notification to terminate the authorization.
Authorized Signature:
Clear
Date
-
Month
-
Day
Year
Date
Credit Card Information
Name on Card
First Name
Last Name
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I authorize the above practice to charge my credit card in accordance with the information above.
Signature (as it appears on the credit card)
Clear
Date
-
Month
-
Day
Year
Date
Please provide a voided check if using a checking account.
Submit
For Office Use Only
Patient Number
Date
-
Month
-
Day
Year
Date
Should be Empty: