KAP Payment Form

Please correct the errors described below.

Credit Card Payment Form

Kid Approved Pediatrics is now setup to process payments for statements & outstanding balances through our secure online form.

  • I understand that my cc will be vaulted securely in a HIPPA compliant cc system for current/future payments..
  • I understand that should my cc on vault be declined in anyway, KAP will require another form of payment. If secondary payment is un-successful by means of contact or not able to process payment, KAP may choose to suspend patient from future appointments till payment or outstanding balances are resolved.
  • I may revoke the right to have a cc vaulted by contacting KAP in writing either by mail or email: staff@kidapprovedpediatrics.net.
  • I authorize KAP to charge the cc for payment list below.
  • I authorize KAP to vault my cc for future payments.

Patient Statement Info

Payee Billing Address

This will be used for contact purposes only

Payee Payment Info

Must be 16 num
Must be 3 #

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents.

This will be used for contact purposes only
    Please upload a file

    Your message will be encrypted and can only be read by Kid Approved Pediatrics.