Credit Card Authorization Form

Authorization for Credit Card Payments

Thank you for choosing Lindsay Keith, M.D. PLLC. To facilitate the payment process for any outstanding balances, we provide a secure method for you to authorize the use of your credit card. This form collects your consent to charge your credit card, which our front desk will securely obtain over the phone.

By submitting this form, you agree to the following terms:

Phone Authorization: You will provide your credit card details directly to our front desk staff over the phone. These details will be securely entered into our Electronic Medical Records (EMR) system.
Secure Processing: All credit card information will be processed securely and in compliance with industry standards.
Payment of Balances: By giving consent, you authorize the use of your credit card for the payment of outstanding and future balances on your account.
Receipts: You will receive an email receipt for each transaction made using your credit card.
Cancellation: This authorization can be revoked at any time by providing written notice.