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Billing & Agreements
Credit Card Authorization Form
Authorizes charges for deposit and/or services under the Private Pay Agreement.
About 3 minutesCardholders
Credit Card Authorization Form
Paper form for your protection
For your protection, card numbers and security codes are never collected on our website. Please print this form, complete it by hand, and return it to our office in person.
Cardholder details
Authorization
I hereby authorize Golden Grace Health Care LLC to charge this credit card for deposit and/or services rendered under the Private Pay Agreement. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement.
Cardholder Signed *
By signing, you agree this electronic signature is the legal equivalent of your handwritten signature.