Credit Card Authorization Form

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:

1. FOR EACH SERVICE AT THE TIME OF SERVICE provided to me by a service provider of TMG.
2. FOR A MISSED APPOINTMENT at the rate of $85 if I cancel less than 24 hours in advance of my appointment.
3. IF AND WHEN MY PAYMENT BALANCE BECOMES PAST DUE. My service provider will inform me about this charge.

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.

PLEASE COMPLETE

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.