Payment Authorization Form
Please provide the following information for us to contact you with important information about your account.
Responsible Party Information
Responsible Party Name (If Different than Patient):
City: State: Zip:
Home Phone: Cell Phone:
If calling or texting your mobile number is not acceptable to you, please check the corresponding boxes below:
Do not call my mobile number Do not text my mobile number
Payment Authorization for Automatic Payments
Our financial policy requires patients to have a form of payment on file to satisfy any patient responsibility. If you have provided insurance coverage to us, we will bill your insurance company with the necessary information. The balance remaining after insurance has been applied is your responsibility, including insurance deductible amounts. Our office will send an invoice to you once your patient balance is determined. The credit or bank account listed below will be automatically charged on the due date specified on your next invoice.
Please provide either a Credit Card or eCheck information
ECHECK Credit Card
Account Number: Credit Card Number:
Routing Number: Expiration Date:
Name on Account: CVV Code:
Street Address: Street Address:
I authorize St. Vincent's St. Clair Sleep Center to execute transactions on the above account. I consent to the use of the above payment method without my signature on the individual transactions in satisfying my obligations to St. Vincent's St. Clair Sleep Center. I understand that a photocopy or fax of this agreement will serve as an original, and payment authorization cannot be revoked unless done so in a 30-day written notice to the provider.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Payment Authorization Form
Agree & Sign