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Credit Card Information

I authorize Kerzner Associates, P.C., to keep my credit card information securely on file. My credit card can be used for payment under the conditions I have initialed below:

to cover all copays, co-insurance charges and/or applicable deductible amounts incurred at the time of each visit

to cover any late appointments / cancellation fees

for any balances due for over 30 days

to settle any balances due upon termination of treatment 

to receive e-mail receipt of transaction.

I can revoke this authorization at any time by submitting a request in writing to my clinician and/or Kerzner Associates administrative staff

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