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:

Initials

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

Patient Name

Cardholder Name (If Different)

Cardholder's Signature

Card Number

Please Enter: Credit, Debit, HSA, or FSA

Expiration Date

Zip Code

Security Code

Date Signed