CREDIT CARD PRE-AUTHORIZATION – ADMIN – Pediatric People

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CREDIT CARD PRE-AUTHORIZATION – ADMINMichael2021-03-18T08:36:46-05:00

CREDIT CARD
PRE-AUTHORIZATION – ADMIN

DATE OF SERVICE*
PAYMENT METHOD*
- Genterate a payment link.
- Charge CC on file in Healthfusion.
- Cash Payment
- Other, see notes.
HOW MANY CHART NUMBERS ATTACHED TO PAYMENT?*
- 1
- 2
- 3
- 4
- 5
- 6
CHART NUMBER 1*
CHART NUMBER 2*
CHART NUMBER 3*
CHART NUMBER 4*
CHART NUMBER 5*
CHART NUMBER 6*
LAST 4-DIGITS OF CREDIT CARD*
PAYMENT / AUTHORIZATION AMOUNT*
NOTES
PAYMENT AUTHORIZED BY*
- George
- Logan
- Rebecca
- Nikki
- Janelle
- Stella

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