Authorization for Credit Card Use



Michael D. McGee, M.D.

Office: 805-459-8232
Cell: 978-360-6071

Fax: 877 399 5883

Email: mdm@wellmind.com

Board Certified, General Adult Psychiatry, Addiction Psychiatry and Psychosomatic Medicine

6613 B Bay Laurel Place, PO Box 2589, Avila Beach, CA 93424


 

COMPLETE THIS AUTHORIZATION and click “Submit” on the bottom of the form.

All information will remain confidential and protected.

 

Patient Name:

Name on Card:

Billing Address:

Credit Card Type:

Credit Card Number:

Expiration Date:

/

Card Identification Number:

(last 3 digits located on the back of the credit card)

 

I authorize WellMind LLC to charge the amounts listed in my Treatment Agreement for services provided to me during my treatment to the credit card provided herein. I agree to pay for these purchases in accordance with the issuing bank cardholder agreement.

Leave this empty:

Signature arrow


Signature Certificate
Document name: Authorization for Credit Card Use
lock iconUnique Document ID: b277e903cba203e836a1a6de85d920d972846cc1
Timestamp Audit
March 9, 2016 12:22 pm EDTAuthorization for Credit Card Use Uploaded by WellMind Administrator - mdm@wellmind.com IP 84.17.45.6