Medical Billing Payment Authorization Form
Patient Information
Full Name
Date of Birth
Address
Phone Number
Email Address
Payment Information
Payment Method
Credit Card
Debit Card
ACH/Bank Transfer
Check
Other
Amount Authorized
Name on Account/Card
Account/Card Number
Expiration Date (if applicable)
Routing Number (if applicable)
Security Code (if applicable)
Authorization
Authorization Details
I authorize the above payment and certify the information provided is correct.
Signature
Date