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Credit Card Payment Authorization
Recurring Credit Card Payment Authorization
Last 4-digits of Card
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.