Patient Name
*
Patient Name
Patient Name
First Name
*
First Name
First Name
Last Name
*
Last Name
Last Name
Email
*
Email
Email
I authorize Elliot Davis, DDS, to charge my payment card for the balance of the fees not paide by a third party (i.e my insurance company) within 45 days of the initial date of filing
This visit only, not to exceed $
*
This visit only, not to exceed $
This visit only, not to exceed $
All visits in the next year, beginning
*
All visits in the next year, beginning
All visits in the next year, beginning
Recirring charges, date(s) of service
*
Recirring charges, date(s) of service
Recirring charges, date(s) of service
Not to exceed $
*
Not to exceed $
Not to exceed $
monthly
semimonthly
weekly
per visit
Card holder Name
*
Card holder Name
Card holder Name
Credit Card Number
*
Credit Card Number
Credit Card Number
Expiration Date
*
Expiration Date
Expiration Date
Today's Date
*
Today's Date
Today's Date
i assign my insurance benefits to Elliot Davis, DDS. I understand this form is valid for one year unless I cancel the authorization through written notice to Dr. Elliot Davis.
80 5th Avenue. Suite #1607
New York, NY 10011
001+212.645.9255
Copyright @ 2008. All rights reserved.
