Credit Card Authorization Form Credit Card on File Authorization I authorize East Portland Pediatric Clinic (EPPC), to charge co-payments not paid at time of service, and or unpaid 30 day balances due under $100 to the credit card listed below. For balances over $100, we will attempt to contact you to discuss payment terms. This authorization will remain in force on each of my children's accounts until they are no longer patients of EPPC or until a written request by the cardholder instructing EPPC to remove the authorization has been received. *For patients age 18 and older HIPAA restrictions apply. Please give your card to the Front Desk to be scanned into our secure system. Please choose one: VISA MC DIS AMEX Last 4 digits of cardName on the cardCardholder signatureCardholder email for payment receipts Date of authorization MM slash DD slash YYYY Patient Name First Last Patient's Date of Birth MM slash DD slash YYYY Patient Name First Last Patient's Date of Birth MM slash DD slash YYYY Patient Name First Last Patient's Date of Birth MM slash DD slash YYYY Patient Name First Last Patient's Date of Birth MM slash DD slash YYYY Patient Name First Last Patient's Date of Birth MM slash DD slash YYYY Patient Name First Last Patient's Date of Birth MM slash DD slash YYYY Δ
