Recurring Payment Minimum Balance Due: $100.00
Minimum Monthly Payment: $25.00
Payment Terms Available: 60, 90, 120, 150, 180 Days
I hereby authorize my healthcare provider to charge my credit card for services related to my care. I understand this authorization will remain in effect until I cancel or I contact my healthcare provider to either cancel or arrange an alternative payment method. I will not dispute charges with my credit card company without first making an effort to resolve with my healthcare provider's billing department. I agree to contact my healthcare provider with any questions regarding my account or services.