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.

    Favored Medical Billing Logo

    Are you a medical provider interested in medical billing and coding services?
    Get started now!

    General Inquiries

    Please send us a brief message
    and we will follow up with you shortly!
    Stay Connected