Advanced Health and Education LLC Payment Auth CC

SF Lead ID

Name*

First NameLast Name

Client Name ( First Name, Last Initial )*

First NameLast Initial

Client Phone Number*

Please Enter the CC Information Below: Please note this has to be entered twice for authorization and confirmation purposes.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Credit Card NumberAcct #*
Security Code CVV*
Expiration Date   Exp. Date*

MC*

Payment Authorization- Please Confirm Detail*

USDTotal Amount of Charge Authorized

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Phone Number*

Description of Charges*

Email for receipt*

example@example.com

Cardholder Initials*

By signing this form, you authorize Advanced Health and Education LLC to charge your card for the amount listed above.

As the cardholder, I hereby authorize Advanced Health and Education LLC to charge my credit card and confirm that the information for the credit card and billing address is complete and accurate. I have completed this form to authorize Advanced Health and Education LLC to charge the credit card provided according to the terms outlined below.

Buyer gives Advanced Health and Education LLC permission to charge the card entered or debit the bank account provided for the services rendered. By completing this form purchaser authorizes payment for the charge listed. Charges can be applied toward any and all healthcare services. If cancellation occurs prior to admission to the facility, there will be a 15% non-refundable fee incurred by the canceling party. Therefore, 85% will be refunded to the payor.

Cardholder/Buyer gives Advanced Health and Education LLC permission to charge the card entered or debit the bank account provided for the services rendered on or after the stated date on this form. By completing this form purchaser authorizes payment for the charge listed.

Date*

Date

Signed*

I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above-noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF), I understand that Advanced Health and Education LLC may, at its discretion, attempt to process the charge again within 30 days and agree to an additional $35.00 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions or credit card transactions applied to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute this transaction with my bank or credit card company; so long as the transaction corresponds to the terms indicated in this authorization form.

All In Solutions Contact Email

Credit Card Authorization Form