Payment Information

Membership includes regular Followup Visits on a 4 week recurring schedule.

Monthly billing will be charged on either the 1st or the 15th of each month at a rate of $250 per month. If more frequent or additional visits are required, extra visits will be invoiced as needed.

Billing Preference & Credit Card Authorization Form

Your billing preferences will be updated based on your response to the following questions.

Starting January 1, 2025, a credit card must be saved on file and a credit card authorization form must be completed by the cardholder making payment. The information below will be saved to file for future transactions.

Please complete all fields. You may update your card on file at any time by completing a new form or by contacting our office. This authorization will remain in effect until cancelled.

The cardholder below authorizes payment for services rendered to the patient and for balances that may be owed in accordance with OnCall Pain's Financial & Office Policies.

Patients First name

Patients Last name

Credit Card Type

American Express

Discover

Mastercard

Visa

Cardholder Name (as shown on credit card)

Credit Card Number

Credit Card Expiration Date (mm/yy)

Cardholder ZIP Code (from credit card billing address)

Credit Card CVV Number

I authorize OnCall Pain to charge my credit card for services rendered to the above patient and for balances that may be owed in accordance with OnCall Pain's Financial & Office Policies. I understand that my information will be saved to file for future transactions.

Cardholder Signature

Thanks for submitting! Your credit card information and billing preferences will be updated for visits on or after January 1, 2025.

Payment Information

Billing Preference & Credit Card Authorization Form

OnCall Pain

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