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 Information

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled.
Card Type:*

Cardholder Name:*
(as shown on card)
(from credit card billing address)
(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.

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