Credit Card on File Billing Authorization Form

Credit Card on File Billing Authorization Form

Kunj Patel Medical Doctor PC DBA CRISSP Longevity Clinic
CRISSP Longevity Clinic is offering a secure and convenient method of payment for the portion of services for which you are liable, or for goods that are purchased to facilitate your care. Your credit card information is kept confidential and secure.
Credit Card on File Billing Authorization FAQ
Q: How does the automatic billing process work?
A: Your credit card will be captured today and stored securely. Your credit card on file will be charged when you have a balance owing on your account or for a non-covered service.

Q: How will I know how much you are going to charge me?
A: You will be informed prior to charging you for any services.

Q: What if I need to dispute my bill?
A: We will always work with you to resolve any issues. We generally do not issue refunds, unless we have made a billing error.

Q: Will I receive a statement or receipt for the charges automatically billed to my card?

A: Not automatically. You can at any time contact us to have an account itemization emailed to you.

Q: Is my credit card secure?
A: Yes, we do not store your sensitive credit card information in our office. Keeping your card on file, offsite, in an encrypted payment gateway actual enhances security because it reduces exposure at each visit.
I, First Name* Last Name* , authorize CRISSP Longevity Clinic to capture my credit card information and securely store my credit card on file. I authorize CRISSP Longevity Clinic to charge my credit card on file for any balance owed.
I understand that this form is valid until I give a 30-day written notice to cancel the authorization to CRISSP Longevity Clinic. Written notice must be submitted to CRISSP Longevity Clinic, 20500 Belshaw Ave, DPT 2110, Carson, CA 90746-3506 or by email to longevity AT crissp.net

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.
Patient or Client Name:*

First NameLast Name
Date of Birth (MM-DD-YYYY):*
Credit Card Number:*
Expiration:
MM/YY
CVV/CVC
Email Address:
Cardholder's Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

Credit Card on File Billing Authorization Form

Credit Card on File Billing Authorization FAQ