Payment Authorization Policy Form in Virginia, Washington D.C. and Maryland IF PAYING FOR YOURSELF:Name(Required) Email(Required) Date of Birth(Required) MM slash DD slash YYYY BY TYPING YOUR NAME IN THE “Patient Signature” SPACE, I agree that I am paying for my product/procedure/service by credit card. I attest that this is in fact me and I am the authorized card holder. Since medical records are private, confidential and protected according to HIPAA laws, limiting merchants/vendors from providing information in case of chargeback disputes, I agree that I am satisfied with my transactions and will not dispute this or future changes anytime in the future.Patient (or legal guardian) Sign Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY IF PAYING FOR SOMEONE ELSE:BY TYPING YOUR NAME IN THE “Friend/Relative” SPACE, I agree I am paying by credit card for my product/procedure/service received by Friend / relative who is a friend/relative. I attest that this is in fact me and I am the authorized card holder. Since medical records are private, confidential and protected according to HIPAA laws, limiting merchants/vendors from providing information in case of chargeback disputes, I agree that I am satisfied with my transactions and will not dispute this or future changes anytime in the future.Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Δ
