Update Billing Database Form

Update/Change Database Form

This form is used to update or change your billing information
Name of person updating billing information

First NameLast Name
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Format: (000) 000-0000.
New Payment Method

We do not collect detailed credit card numbers and bank information on this form. One of our staff members will call you to finalize your new billing information.
Change my payment method
What type of credit card do you want to use?
How we use your email address:
- Our recurring billing system will automatically generate an e-mail notifying you of any action taken on your account, including but not limited to monthly billing statements.
- This email address will not be used to update patients on other events regarding Personal MD.
- Personal MD will not sell or share your email address for any reason.
Email Address
example@example.com
Signature:

With my signature, I authorize that I can legally authorize changes to my billing account. My billing information can be used by Personal M.D. Family Healthcare, P.A., including using a credit card or bank information for recurring billing of services, payment of lab services, radiology services, injections, supplements, missed appointments, insufficiently funded checks plus penalties, and billing for seeing another member on your account, such as a child.
DateTime
Signature
Should be Empty:

Update/Change Database Form