ALTZ01 Storage Form for Credit Cards

Altoona Dermatology now offers the option to securely store your credit card details for future payments. This will streamline our billing process and ensure convenience for our patients.

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

If you choose to have your card information stored, please advise of your notification preferences.

I choose NOT to be notified of balances applied to card

I would like to receive a text message notification of pending charges and date

I would like to receive a statement and then phone in permission to charge

By signing below, you authorize us to store your credit card information and to charge your card for copays, deductibles, or any remaining balances. You may revoke this authorization any time by notifying the office.

I agree to notify Altoona Dermatology Associates if this card expires. Any new card information given in person or over telephone may be used under this authorization also.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature *

Date *

Date