Authorization Form for Automatic Payments

Please correct the errors described below.

By signing below you authorized Winghaven Pediatrics to process payments for balances incurred after insurance processing for services provided to your family. An emailed receipt will be sent to you when payment are processed.

OR

Please read and sign below:

By signing below I am authorizing WingHaven to automatically withdraw my account balance anytime a new balance is incurred from my credit card/checking account above. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

If you prefer not to participate please check below and sign to indicate that you understand your claim. If we do not receive your payment within 30 days of the statement, you will be charged an additional $10.00 for every 30 days past due.

decline the option to have payments for balances processed automatically. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

E-BILLING AUTHORIZATION FORM

As an e-billing customer, you will no longer receive a paper bill in the mail. Instead, you will receive electronic notification by e-mail when you have a bill due. The email notification will provide you with a link to view and pay your bill on our secured payment website. (If you are not interested, in this time and money saving service please check the box at the end of the page. Thanks.)

Please list all children in your family that are patients at Winghaven Pediatrics.

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