I, as the Cardholder(s), hereby authorize Milan Patel, MD and/or his business associates to charge my statement balance for my account to my primary or secondary credit card according to the guidelines listed below.
The secondary credit card will be used in the event that an approval cannot be obtained for the primary card number. I authorize Milan Patel, MD and/or his business associates to charge the credit cards listed below in the event that I default on payment for services rendered.
I, as the Cardholder, will be responsible for notifying, in writing, Milan Patel, MD and/or his business associates one month in advance if cancellation of this service is requested, or if there are any other changes to the credit card information below.
Please note there is an additional fee of $75/quarter-hour for completion of disability forms and/or treatment summaries, and complex prior authorizations outside the appointment time.