Card on File: Authorization Form

Card on File: Authorization Form
Information to be completed by cardholder:

The undersigned agrees and authorizes medical practice to save the credit card indicated below on file. The use of this form is optional and for your convenience.
Medical Practice
Patient’s Name
Name as it Appears on the Credit Card
Type of Credit Card
Last 4 Digits of Card
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I, your name authorize the above medical practice to process the above credit card as “Card on File”. I understand this authorization will remain in effect until the expiration of the credit card account. Patient may also revoke this form by submitting a written request to the medical practice.
Cardholder's Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: