core4therapy_Permission_to_Bill_Credit

Permission to Charge Credit Card
I give Core4 Therapy Group continuing permission to make charges to this credit card and renewals of it for therapy services rendered and for goods purchased. I agree to pay such charges to the issuer of the credit card without dispute. The charges will be for the amounts of the patient responsibility per the patient's insurance policy and Core4 Therapy financial policy. Charges might include but not be limited to co-pays, deductibles, co- insurance, non-insured covered charges, or purchase of merchandise. Patients seen outside of the office must keep a card on file.
Please routinely charge my patient responsibility at the time of service or when insurance explanation of benefits (EOB) is received from services rendered (Initial)
Name on Card
Card first 4 digits
second 8 digits
last 4 digits
Expiration
CVC Code
If you have questions about your payment options, please do not hesitate to ask. We are here to help and provide therapy services you want or need.
Patient, Parent or Guardian Signature, Authorized Representative or Responsible Party

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Patient Name Please Print
Patient DOB

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Permission to Charge Credit Card