Payment Information Form

CANDIDA FINK MD

12 Parcot Ave New Rochelle NY 10801

P: (877) 534-1090      F: (855) 223-5458

  www.finkshrink.com

 

CREDIT CARD AUTHORIZATION FORM

              Please make sure this form is complete before submitting

 

For your convenience you may keep a credit card on file with the office.  Please note the following:

 

I understand and accept the terms of the appointment change, cancellation, and no-show policy as outlined in the Treatment Agreement – which can be found online at the website or you may request a printed copy.  If the credit card is declined I will be expected to supply another credit card number or pay by other means and I understand that I am responsible for payment in full.

Name as it appears on the card: ______________________________________________________

 

Patient Name (if different than credit card holder):________________________________________________

 

Billing Address:_______________________________________________

Billing Phone Number:_______________________________________________

 

Credit Card Number – Visa, Mastercard, AMEX or Discover:__________________________________________

 

Security Code:   __________         Expiration Date: _________

Email address: _______________________________________________

 

 

Please initial:  It is OK for the office to email me regarding billing matters ______

 Cardholder Signature:    ________________________                                  Date:____________________

 

Please print this page and return it in any of the following ways:

 

US mail:              12 Parcot Ave New Rochelle NY 10801

Email:                 carol@finkshrink.com

Fax:                    914-560-2106

 

Or bring to the office during an appointment.

Thank you.