PATIENT PORTAL / PAYMENT ARRANGEMENT AGREEMENT

Client Payment / Automatic Draft Form

To make a payment or set up a payment plan, please complete and return the form below.


    Client Payment / Automatic Draft Form
     
    VISA MasterCard Discover Care Credit
    YES NO
    Payment Plan. Auto Debit.
    I agree to the below outlined payment arrangement to satisfy the current outstanding balance on my account.
    Biweekly (on Fridays) Monthly (the 28th of each month)
    *A copy of this completed form will be sent to your provided Sender Email address.





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