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ANNA BUDAYR, MD
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Diplomate, American Board of Psychiatry and Neurology
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ANNA BUDAYR, MD
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BILLING AUTHORIZATION FOR CREDIT CARD OR BANK DEBIT CARD
BILLING AUTHORIZATION
Date
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Name
*
First Name
Last Name
Email Address
*
Credit Card Type
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Visa
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Credit Card
Name on Credit Card
First Name
Last Name
Security Code
Exp. Date
Card Billing Address
Address 1
Address 2
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OR Debit Card Number
Name on Account
First Name
Last Name
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Electronic Signature
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First Name
Last Name
Date
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Thank you!
PAYMENT POLICY & CREDIT CARD AUTHORIZATION FORM
PAYMENT POLICY & CREDIT CARD AUTHORIZATION FORM
Missed Appointments & Late Cancellations
If you miss or cancel your appointment with less than 48-hours notice the equivalent of one session fee may be charged to your card. Please note that insurance companies do not reimburse for missed appointments.
Outstanding Balances
If you have accrued an outstanding balance for services, and have not made specific arrangements for payment for over 30 days from the last date of service, your card may be charged for the balance due.
I authorize my credit card be charged in the following circumstances: • A scheduled appointment that is missed or cancelled less than 48 hours in advance • Outstanding balance for services over 30 days delinquent If I have any problems or questions regarding charges to my account, I will contact Anna Budayr, MD for assistance. I agree that I will not dispute any charges with my credit card company until I have attempted to rectify the situation directly with Anna Budayr, MD.
Electronic Signature
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First Name
Last Name
I have read, understand and agree to the above fee payment and credit card policy for services provided by Anna Budayr, MD:
Electronic Signature
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First Name
Last Name
Date
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Credit Card Information
Name on Card
*
First Name
Last Name
Card Type
*
Visa
Mastercard
Discover
American Express
Credit Card Number
*
Security Code
*
Exp. Date
*
Billing Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Thank you!