Credit Card Authorization

Please review and know your co-pay and applicable deductible for your health insurance policy. All payments are required at the time of your visit.
Deductibles are the client’s responsibility and required prior to appointments. We will bill your insurance company, so you receive credit towards your deductible.
A valid credit or debit card is required and kept on file for unpaid balances over 90 days. This card will also be charged $75.00 for missed appointments/late cancellations, as per our policy if not cancelled 48 hours prior to scheduled appointment. Monday appointments that are not cancelled by 1:00 pm on Friday are considered late cancellations.
Any accounts over 30 days will be subject to a $5.00 monthly late fee. Accounts over 90 days will be sent to collections and fees will be the responsibility of the client.

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Cardholder Name (as shown on card):

16 digits of Card Number:

CVV:

Expiration Date (mm/yy):

Cardholder ZIP Code (from credit card billing address):

Authorize CREATIVE MEDICAL CONSULTING to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

Signature

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Please type full name here

Date