Peninsula Doctor Membership Payment

Please correct the errors described below.

Peninsula Doctor is a subscription service. Your membership starts the day that you join the practice, i.e. sign the agreement, or receive medical services. You have the option of paying monthly, quarterly or yearly. Your membership will continue until you notify us otherwise. In the event that you decide to leave the practice, we require a one-month notice for cancellation. We will continue to provide services during this month.

Payments

Automatic payments can be made by Credit Card or ACH only. If you prefer to pay by check we offer an annual payment option.

Credit Card Authorization

If paying by credit card, please fill out the information below. If patient is the credit card holder, please fill out credit card information section below and leave the address section empty.

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.

I hereby authorize the office of Peninsula Doctor to charge this credit card for practice membership fees.

ACH Authorization Form

If paying by ACH direct deposit, please fill out the information below.

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.

I authorize Peninsula Doctor to electronically debit my account and, if necessary, electronically credit my account to correct erroneous debits.

I understand that this authorization will remain in effect until I (we) notify Peninsula Doctor in writing, that I (we) wish to revoke this authorization. I understand that Peninsula Doctor requires a one-month's notice in order to cancel this authorization.

If the payment is rejected due to non-sufficient funds (NSF), I understand that Peninsula Doctor may attempt to process the transaction again within 10 days and I agree to an additional $30 NSF rejection fee charge for each attempt that is returned due to NSF, which will be initiated as a separate transaction from the authorized payment.

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