Care Credit Authorization Request
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Zip Code
*
Which program do you want to enroll in? :
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Please Select
Adult Autism Program - $615
Adult ADHD Program - $615
Combined Adult Autism/ADHD Program -$780
By signing this, I authorize LBee Health Practice Group, PLLC to request a payment link from Care Credit to use towards payment of the service/program selected above.
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