Credit/Debit Card Payment Authorization Form

Credit/Debit Card Payment Authorization Form
I authorize Corridor Mobile Medical Services to charge my credit/debit card for a one time payment or once a month for the X-ray services that were performed. There is no fee for utilizing this payment method.
Type of Card:
Credit Card Number
Expiration Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CVV:
Name of Cardholder:

First NameLast Name
Cardholder Phone Number:
Format: (000) 000-0000.
Cardholder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name and Phone Number of Alt Contact:
Email Preferences
Email Address:
example@example.com
Payment Options
I understand that this authorization will remain in effect until any open balances are paid in full. I agree to notify Corridor Mobile Medical Services in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment date falls on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the organization of Credit Card transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions, so long as the transaction corresponds to the terms indicated in this authorization form.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Office use only: Account #
Invoice #
* 783 N. Loop 337 * New Braunfels, TX 78130-3632 *
Billing Dept. 512-392-4416 * Fax 512-519-2423 * Email: Payments@cmmsxray.com *
Billing Hours: 7am-3pm CST
Should be Empty: