RPM Credit Card payment and Consent

RPM Credit Card Payment and Consent
Name on Card*
Billing Address*
City*
State*
Zip*
Phone Number*
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Authorization to Store Credit Card Information

This stored information will be used solely to process charges related to Remote Patient Monitoring (RPM) devices not returned or returned in damaged condition. I may revoke this authorization at any time by:
- Submitting written notice to Home Physicians Group
- Returning all RPM equipment in working condition to Home Physicians Group
Authorization and Acknowledgment

By signing below, I authorize Home Physicians Group to charge my credit card only if I fail to return RPM equipment or return it damaged. I understand that:
- | am not being charged for participation in the RPM program.
- I will be notified prior to any charge being made.
- Replacement costs may include tablets, monitoring devices, and accessories, as outlined in the patient agreement.
Data Security Acknowledgement

Home Physicians Group has implemented technical, administrative, and physical safeguards to protect your personal and financial information from unauthorized access, disclosure, or misuse. While no system can offer 100% protection, reasonable and appropriate measures are in place to secure your data.

Consent and Signature

By signing below, I acknowledge that I have read and understood the information above and agree to the terms of this authorization.
Patient Name*
Date of Birth*

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Signature*

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Credit Card Number (Complete Number)*
Expiration Date*
CVV (3 or 4 digits):*
Today's Date*

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Date
Should be Empty:

RPM Credit Card Payment and Consent