Credit Card Authorization Form "*" indicates required fields NeuroPsychiatry Center - Ravi Kant, MD, P.C. 300 Old Pond Road, Suite 201, Bridgeville, PA 15017 Tel. # 412-220-7323 Fax # 412-220-7325 Credit Card InformationPlease complete all fields. You may cancel this authorization at any time by contacting us in writing. This authorization will remain in effect until cancelled. Card Type:* MasterCard VISA Discover AMEX Other Cardholder Name:*(as shown on card) First Last Last 4 digits of Card Number:* Expiration Date (mm/yy):* Cardholder ZIP Code:*(from credit card billing address) CVV:*(3 digits on the back of the card) I authorize NeuroPsychiatry Center to charge my credit card listed above for services provided. This can include self-pay fees, co-payments, deductible, and other charges such as no-show fees, and services not covered under my insurance. I understand my credit card will not be charged more than $300 at one time. I understand that my information will be saved on file for future transactions on my account. I am responsible for keeping this information updated in a timely manner.I certify that this data is true, correct & accurate. I understand that payment of this claim will be from federal & state funds. Any false claims, documents, or concealment of material facts may be prosecuted under applicable laws. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.Patient/Guardian Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY
