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. This authorization will remain in effect until canceled.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 your insurance. 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. Patient/Guardian Signature*Date* MM slash DD slash YYYY
