CONSUMER Credit Card PAYMENT AUTHORIZATION FORM

CONSUMER Credit Card PAYMENT AUTHORIZATION FORM
Jack L. Koch Jr., M.D., PLLC
1507 16th Avenue S.
Nashville, TN 37212
(615) 515-7775
I (we) authorize Jack L. Koch Jr., M.D., PLLC to electronically charge my (our) credit card account (And, if necessary, electronically credit my (our) account to correct erroneous debits) as follows:
Credit Card Type*

VISAMaster Card
I authorize electronic ACH debits / credits to the depository financial institution named below (“DEPOSITORY”). I (we) agree that ACH transactions I (we) authorize comply with all applicable law.
Name on Card*
Patient Name (if different)

First NameLast Name
Credit Card Number*
Expiration Date*
CVV*
3 digits
Billing Zip Code*
Dates and/or Frequency of Debits*

With provision of treatment services
I (we) understand that this authorization will remain in full force and effect until I (we) notify Jack L. Koch Jr., M.D., PLLC in writing that I (we) wish to revoke this authorization. I (we) understand that Jack L. Koch Jr., M.D., PLLC requires at least 15 days prior notice in order to cancel this authorization.
I certify that I am an authorized signer for the account indicated above and that I have the authority to authorize this/these transactions. I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date, and that I will have limited time to report and dispute errors. I agree not to dispute this transaction with my bank provided the transaction corresponds to the terms indicated in this authorization form.
I agree to the terms and conditions described above.*

Yes
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date*

MonthDayYear
Date
Signature*

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