LHL-Recurring Credit/Debit Card Payment Authorization Form

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Recurring credit/debit card payment authorization FORM

Patient Name:

DOB:

I understand and authorize LH Langley, PLLC to charge the credit/debit card on file the amount due at the time services are rendered. I also understand that this card will be charged the full fee for service if I do not give 48-hour notice of cancellation or if I miss/No Show the appointment. This fee is outlined in the Office Policies Form.

Name On Card:

Mastercard Visa

Credit Card Number:

Expiration Date:

CVV code:

Billing Address:

Billing Zip Code:

Signature of Patient or Legal Guardian

Date

Print Name:

I authorize the above named business to charge the credit/debit card indicated in the authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termation of this authorization at last 7 days prior to the next appointment. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit/debit card and that I will not dispute the scheduled payments with my credit/debit card company provided the transactions correspond to the terms indicated in this authorization from.