Payment Authorization Form


Please provide the following information for us to contact you with important information about your account.

Responsible Party Information

Patient Name:

Responsible Party Name (If Different than Patient):

Billing Address:

City:      State:      Zip:

Email Address:

Home Phone:      Cell Phone:

If calling or texting your mobile number is not acceptable to you, please check the corresponding boxes below: 

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:

City:                                           City:

Zip:                                                                  Zip:

 

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.

Signature:      Date:

Leave this empty:

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Signature Certificate
Document name: Payment Authorization Form
lock iconUnique Document ID: eca09ae2eb187fbd6240702ddd92a732995f5701
TimestampAudit
January 25, 2021 1:53 pm CSTPayment Authorization Form Uploaded by Dylan Richardson - dylan@danmarkcom.com IP 12.233.60.59