Securely authorize payment by credit, debit, or HSA card for services rendered.
Providing credit or debit card information is completely voluntary and is not required to register as a patient.
I give my permission for the HKD Outreach PC to charge my credit/debit card or HSA card for services rendered. I understand that in giving my permission, my noted account will be charged the full agreed upon fee/patient responsibility due, normally within a week of when services were rendered.
I agree to notify the HKD Outreach PC in writing of any changes in my account information or in the event that I choose to withdraw authorization for recurring payments. I also understand that if a payment is returned for Insufficient Funds, the HKD Outreach PC may attempt to process the charge again, and I agree to any additional applicable charges added to the full amount due as reimbursement for any incurred fees.
By providing my signature (on paper or electronic) to this document I am attesting that I understand and accept the above stated terms and I hereby authorize the HKD Outreach PC to charge my below listed card for recurring payment for services provided.
