Patient Payment Form

Patient Payment Form
  • Credit Card Payment Authorization Form

  • Sign and complete this form to authorize Dr. Justin Marchegiani to bill my credit, debit, flex or HSA card listed below.
    Please complete the information below:
  • authorize Dr. Justin Marchegiani to charge my credit card as listed below. Please attach a copy of your insurance card front and back if Dr. Justin has requested it.

  • This authorization may be revoked at any time when the following stipulations have been performed:
    1. Patient has already made new financial agreement that has been signed and dated or card holder/patient has submitted to our office a written request to revoke the card usage (stop billing credit card in writing signed and dated).
    2. Patient’s account is paid in full.
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