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About PEOPLEinc
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Patient Info
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New Patient Forms
Patient Agreement Form
Telehealth Consent Form
Auto Payment Authorization
Authorization to Release Information
Contact Us
Patient Authorization Auto Payment Form
PATIENT ACCOUNT INFORMATION
Patient Name
*
Billing Email
*
Phone
*
Today's Date
*
MM slash DD slash YYYY
PAYMENT INFORMATION
Card One (to be charged first):
*All Sensitive information is securely encrypted
Name of Cardholder
*
* as it appears on the card
Credit Card Billing Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Credit Card Number
*
*as it appears on card
Expiration date
*
CVV Code
*
Card Type
*
Visa
Mastercard
American Express
Relationship to Patient
*
Self
Parent
Spouse
HSA/Health Savings Card?
Yes
No
Card Two (OPTIONAL - cannot be an HSA Card):
Would you like to enter a 2nd Card?
Yes
No
Add another card
Name of Cardholder
* as it appears on the card
Credit Card Billing Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Credit Card Number
*as it appears on card
Expiration date
Card Type
Visa
Mastercard
American Express
CVV Code
Relationship to Patient
Self
Parent
Spouse
AUTHORIZATION
I authorize PEOPLEinc to charge my account on an as-needed basis to bring the account listed above current. I understand that it is my responsibility to monitor my credit card charges and verify that payments are processed correctly.
Signature of Cardholder
*
IMPORTANT NOTICE: You are responsible to keep your auto payment information on file current. Please submit a new authorization form for any credit card changes, especially expiration dates. If your payment is not processed, it is your responsibility to contact PEOPLEinc for information or submit a revised form with current information to prevent late fees. Please monitor your credit card/bank charges. Please reconcile your account each month.
Questions? Please call 425.623.0661