Integrated Medical Weight Loss

Available Forms

Authorization to Disclose Personal Health Information (PHI) Credit Card Authorization for Integrated Medical Weight Loss Integrated Medical Weight Loss - Policy Acknowledgements New Patient Paperwork Demographics & Health History

Credit Card Authorization for Integrated Medical Weight Loss

Credit Card information & Authorization

With telehealth/virtual appointments still being widely used, we ask that you provide us with a credit card to be used for copayments and deductible payments. Your card information will be held securely in your electronic chart and used only for charges you specify (below).

I authorize Integrated Medical Weight Loss / Yestermorrow PC to charge the credit/debit card listed below for the following charges

Check all that Apply:

Co-Payments

Deductible

Missed Appointment Fee (1st appt-$100, 45 min-$75, 30 min-$50)

I guarantee that I am the legal cardholder for this credit/debit card and that I am legally authorized to enter into this payment agreement. I understand that this office will not charge my credit card for anything other than the reason set forth in this agreement.

Card Holder Name (as shown on card):

Billing Address:

Credit Card Type (MC, Visa, AmEx, Discover):

Credit Card #:

Expiration Date:

Signature (printed)

Card Holder's Name

Date

* Required field