Authorization for Credit Card Use



Michael D. McGee, M.D.

Office: 805-459-8232
Cell: 978-360-6071

Fax: 877 399 5883

Email: mdm@wellmind.com

Board Certified, General Adult Psychiatry, Addiction Psychiatry and Psychosomatic Medicine

PO Box 545, Avila Beach, CA 93424-0545


 

COMPLETE THIS AUTHORIZATION and click “Submit” on the bottom of the form.

All information will remain confidential and protected.

 

Patient Name:

Name on Card:

Billing Address:

Credit Card Type:

Credit Card Number:

Expiration Date:

/

Card Identification Number:

(last 3 digits located on the back of the credit card)

 

I authorize WellMind LLC to charge the amounts listed in my Treatment Agreement for services provided to me during my treatment to the credit card provided herein. I agree to pay for these purchases in accordance with the issuing bank cardholder agreement.

Leave this empty:

General Adult Psychiatry, Michael D. McGee https://wellmind.com
Signature Certificate
Document name: Authorization for Credit Card Use
Unique Document ID: a384783f50d34ac2a1d0a50fdf5b31206fcd2592
Timestamp Audit
2016-03-09 12:22:07 EDTAuthorization for Credit Card Use Uploaded by Lauren Callahan - info@wellmind.com IP 178.158.113.11