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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
Provider Name:
Patient Name:
Date of Service to Apply Payment:
Patient Address (verified, no changes):
Patient Phone (verified, no changes):
Card Type:
VISA
MasterCard
Discover
Care Credit
Card Number:
Expiration Date:
Security Code:
Zip Code:
Payment Amount:
Receipt to be mailed?
YES
NO
Payment Plan. Auto Debit.
I agree to the below outlined payment arrangement to satisfy the current outstanding balance on my account.
Payment Amount:
Arrangement Start Date:
Payments shall be run:
Biweekly (on Fridays)
Monthly (the 28th of each month)
Signature of Responsible Party:
Date:
Sender Email*:
*A copy of this completed form will be sent to your provided Sender Email address.
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