• Recurring Credit Card Payment Authorization


  • Credit Card Payment Authorization plus

  • 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.