TMG uses a secure electronic health record (EHR) payment system. Your provider will enter your credit card information into this system with your permission and charge your account through it.
By signing below I authorize TMG to use the credit card information below to charge my credit card using an on-line system for the following purposes:
I acknowledge that I will be receiving an email with a receipt for the payment, as well as an e-mail with an itemized statement with appropriate information needed to submit to my insurance company and/or for tax purposes.
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.
Your information will be encrypted.