Clone of Authorize Payment Form with CC Surcharge But Not Debit

Account Number*

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Please note that a 3.5% credit card processing fee is automatically added to all credit card payments. No additional fee is added to debit card payments.

If you wish to avoid this fee, please submit an alternative form of payment to our office. Thank you.

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Calculation

Payment Information

USDPayable to Kearney Anesthesia Associates, P.C.

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

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Billing Address

Street Address

Street Address Line 2

City

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Country

Phone Number*

Area CodePhone Number

Your Email Address

Please read our HIPAA/Privacy Notice and acknowledge below.

HIPAA/Privacy Notice Agreement*

Yes, I have read and agree to the Kearney Anesthesia Associates HIPAA/Privacy Notice