Patient Credit Card or Checking Account Authorization

HEALING HANDS HOUSE CALLS, PLLC
4499 Medical Drive Suite 126
San Antonio, Texas 78229
(210)560-5841

Patient Credit Card/Checking Account Pre-Authorization Telemedicine

In an effort to better serve our patients and simplify your billing experience, our office offers credit card acceptance and checking account auto-draft. All information is filed with your confidential patient information and kept secure.

______(initial) CHARGE CARD. I hereby authorize HEALING HANDS HOUSE CALLS, PLLC, to charge my account automatically each month the amount of $50.00/$100.00 (circle one). Card will be charged by the FIFTH of the each month.
______(initial) CHECKING ACCOUNT. I hereby authorize HEALING HANDS HOUSE CALLS, PLLC, to draft my checking account via debit card automatically each month the amount of $50.00/$100.00 (circle one). Checking account will be drafted by the FIFTH of each month.
_____ (initial) I choose to pay my membership fee on a quarterly/annual (circle one) basis. My card or checking account will be charged or drafted the appropriate fee by the FIFTH of the quarterly or annual anniversary date. Quarterly= $200.00 or $400.00 ; Annual= $600.00 or $1200.00.
_____(initial) I choose to pay my non-refundable enrollment fees via CHARGE CARD/DEBIT CARD (circle one) . Per adult is $50.00 ______Per Child is $50.00______.
PAYMENT INFORMATION / Patient Name:
Patient Billing Address:
Type of Card: / / / /
Card Number:
Expiration Date: / Security Code:
(last three digits on card, last four on AMEX)
CHARGE POLICY / ______(initial) Being the authorized cardholder or the account holder, by signing above I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize to charge my credit card or draft my checking account for the services provided. I further agree that in the event my credit card becomes invalid, I will provide a new valid credit card upon request, to be charged for the payment of any outstanding balances owed. I furthermore confirm that I have received all services and goods to satisfactory conditions. Any charges or drafts refused will result in immediate termination of membership.
______(initial) Charges made for membership with our office are non-refundable.