Payment Plan authorization

Payment Plan authorization
Client Name

First NameLast Name
Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
I, Full Name , as a cardholder, hereby authorize Journey Healthcare to charge my credit card ending in XXXX and confirm that the information for the credit card and billing address is complete and accurate.
I understand that I have a current balance due to Journey Healthcare. I understand that the totle balance due must be paid in full within 120 days.

I have been informed that I can cancel the recurring payments by phone, at least 7 days before the payment date.
I authorize Journey Healthcare to run my credit card for the amount of:

$25$50$75$100Total balance amountOther (Payment plans must exceed $25 per month)
I authorize the Journey Healthcare to run my card at the following occurrence

1 payment made on the first of the month2 payments made on the 1st and the 15th of every monthweekly payments on Mondayweekly payments on FridayOther (Payment plan payments must be made at a minimum of one time per month)
Card Holder Name:

First NameLast Name
Credit Card Auth:

Provide Credit CardUtilize Credit Card on file
Card Type:

VisaMaster CardDiscoverAmexOther
Last four digits of card number
Last four digits of CC on file:
Expiration Date:
Vin Number
Date

MonthDayYear
Date
Cardholder Signature

Clear
Should be Empty: