Joyful Roots Chiropractic Credit Application

Joyful Roots Chiropractic Credit Application
If my insurance company fails to pay any portion of my bill, and I do not make a payment within two weeks of your notifying me, Please use my credit card listed below.
Any cash balance on my account will be paid according to the agreed-upon financial plan. If a balance remains thirty (30) days beyond the agreed upon payment date, I hereby authorize you to collect that amount in full on the credit card listed below.
In the event any insurance company obligated by contractual agreement to make payment to me or to you for the charges for a billing period, refuses to make such payment upon demand by you, or does not make payment within sixty (60) days of your billing, i will become personally responsible for that amount. I will have thirty (30) days to clear that account by calling my insurance company after being notified by your office. If the account is not cleared in thirty (30) days, I hereby authorize you to collect any outstanding amount on my credit card listed below.
The signed credit / Debit card is for use only for services in the Chiropractic office below. The doctor agrees not to add any charges directly to my account for services that were not performed or products not purchased.
Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit Card
Credit Card Number
Expiration Date (MM/YY)
CVV
Patient Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: