Credit Card Authorization Form – Medical

Welcome to NATIVE HEALTH!

Thank you for choosing NATIVE HEALTH. At NATIVE HEALTH, we value each of our patients and continually strive to ensure we provide you with excellent care and customer service. To ensure that you do not incur any charges to your account, we ask that you please complete the form below. This form authorizes NATIVE HEALTH to keep your credit card information on file and each time you come in for your appointment, for your convenience, we can use this information to pay for your co-pays.

As a reminder, patients with insurance benefits or on our sliding fee program are responsible for paying their co-payments at the time of their visit. If you are unable to pay, we can charge the credit card we have on file.

Thank You!

By signing and completing the information below you are authorizing NATIVE HEALTH to keep this information on file and charge this credit card for any outstanding copayments that you owe. Please notify NATIVE HEALTH immediately for any changes to this information.
Credit Card Type*
- Visa
- Master Card
- Discover
- American Express
Credit Card Number*
Expiration Date*
MM slash DD slash YYYY
Amount to be Charged*
Complete Mailing Address*
Street Address Address Line 2 City State ZIP
Name on Card*
First Middle Last
Description of what is being paid for:*
Patient Name*
I authorize NATIVE HEALTH to charge my credit card for any outstanding balances to my account:

Patient/Guardian Authorized Signature
First Name*
Last Name*
Email*
Date*
MM slash DD slash YYYY

Credit Card Authorization Form – Medical

Welcome to NATIVE HEALTH!

Patient/Guardian Authorized Signature