Credit Card on File Authorization

I acknowledge that I, the undersigned, am the authorized cardholder for the credit/debit/HSA card indicated below and my signature below authorizes DuPage Pediatrics, Ltd. to keep my credit/debit/HSA card on file. I understand that after claims are submitted and processed by my insurance company, my credit/debit/HSA card will be processed by DuPage Pediatrics, Ltd. for any unpaid balance that is more than 30 days beyond the date of the last statement generated. I also authorize my credit/debit/HSA card to be credited by DuPage Pediatrics, Ltd. if I am due a refund.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Cardholder’s Signature

Date

Cardholder’s Printed Name As It Appears On Card

Cardholder’s Address

City

State

Zip Code

Credit / Debit / HSA Card Number

Expiration Date

Please Choose One:

Visa

Mastercard

Discover

American Express

Patients This Card Applies To (Please be sure to list all children that are patients of the practice):

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