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