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Insurance/Credit card authorization form

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Insurance/Credit card authorization form

Postby Hersheydmd » Mon Oct 31, 2016 4:25 pm

Does anyone have a credit card authorization form? I already have a recurring payment authorization form, but I need a form for the balance after insurance pays. Thanks in advance.
Last edited by Hersheydmd on Tue Jul 18, 2017 8:12 pm, edited 1 time in total.
Robert M Hersh DMD, FAGD
Univ. of Penn 1982
Brooklyn, NY 11234
https://www.facebook.com/pages/Robert-M-Hersh-DMD/118221471599429
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Re: Credit card authorization form

Postby rhaber123 » Wed Feb 01, 2017 11:39 am

check this form and make your own:
http://imaging.ubmmedica.com/all/editor ... POLICY.pdf
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Re: Insurance & Credit card authorization form

Postby Hersheydmd » Tue Jul 18, 2017 8:08 pm

Here is my insurance/credit card authorization form:

2017-07-18.png
2017-07-18.png (122.02 KiB) Viewed 2431 times


Insur_auth-and-credit_card.xml
(32.43 KiB) Downloaded 178 times
Robert M Hersh DMD, FAGD
Univ. of Penn 1982
Brooklyn, NY 11234
https://www.facebook.com/pages/Robert-M-Hersh-DMD/118221471599429
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Hersheydmd
 
Posts: 680
Joined: Sun May 03, 2009 9:12 pm
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