Authorization to Bill for Co-Pay, Deductible, or Outstanding Balance

This is a HIPAA compliant platform.

By signing this form, you give Magnolia Physical Therapy & Wellness, Inc permission to bill services for the remaining amount owed indicated once sessions have begun.

If you choose to have an automatic charge debited from your credit / debit card please fill out the information below. This gives permission for any future authorization for any debits or credits to your account. You will be sent an invoice and receipt with dates of service and charges upon receiving the final billing from Medicare/Insurance.

Please complete the information below:

I authorize Magnolia Physical Therapy & Wellness, Inc to bill me for my co-pay following discharge. I give permission to debit my credit card / debit card. I authorize Magnolia Physical Therapy and Wellness to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for repeat charges that I receive. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

You can expect a phone call within three business days of signing this form to collect your credit card details. Thank you so much!