Name: Pediatric People
Price range: $

Recurring Credit Card Payment Authorization

Cardholder Name*

First Last

Last 4-digits of Card*

Expiration Date*

CVV*

Chart Number(s)*

I authorize Pediatric People, PLLC to charge my credit card 7 calendar days after my statement is mailed for any medical charges that are not paid by my health insurance company. This authorization is in affect for myself and any dependents.

I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify Pediatric People, PLLC in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card.

I will not dispute any transactions from Pediatric People, PLLC with my credit card company; so long as the transactions correspond to the terms indicated in this authorization.

Mail me an itemized receipt after credit card is charged.*

Yes
No

Authorization Date*

Cardholder Signature*