Rose City Pediatrics

Credit Card Authorization

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Insert Credit Card about here

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As an accommodation by Rose City Pediatrics Medical Group (the “Group”) to its valued patients, we will submit all claims to your insurer for pediatric services we provide.  After the claim is processed by the insurer, the Group will charge your credit card for the amount that is outstanding.

If you agree to the terms noted in this Credit Card Authorization form, you authorize the Group   to charge your credit card for the outstanding balance for pediatric health care services provided by the Group.   This credit card is to be used for pediatric services provided by the Group for all your family members.

The Group will mail a notice that your credit card was charged within thirty days of the date of the charge. .

If you agree to the terms set out in this authorization form, please complete the information noted below and sign and date where indicated.

 

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Name of patient                                                                      Prime Clinical #

 

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Name of patient/sibling                                                           Prime Clinical #

 

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Name of patient/sibling                                                           Prime Clinical #

 

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Name of patient/sibling                                                           Prime Clinical #

 

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Parent signature                                                                      DATE

 

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PRINT PARENT NAME