Credit Card Payment Information Form

We offer many ways for you to provide us with your payment information. In addition to visiting our office to take care of outstanding bills you can print out a mail-in form, contact us by phone, or fill out this online form. In all three cases your information is delivered securely to your Patient Accounts Representative who will verify and process the payment information for you

To choose the online method of transmitting your payment information please fill out the form below.

 

Patient Name: Acct#:
Guarantor Name:
Billing Address:
City: State: Zip Code:
Home Phone: - - Work Phone: - -
Pager: - - Cell Phone: - -
Employer: Insurance Carrier:

I hereby authorize Austin Ear, Nose and Throat Clinic (by phone, mail, or online) to apply charges
to the credit card listed below for balance of charges on my account.

Choose One:

One visit only
for $

All outstanding bills

from:
,
to
,

 

Type of credit card: Visa MasterCard American Express s Discover


Name as it appears on the card:

Card ID:
What is this?

Card Number:
Expiration Date:
,
Special Instructions: