Authorization for Credit Card Use


Michael D. McGee, M.D.

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

Fax: 877 399 5883

Email: mdm@drmichaelmcgee.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:

 (3 or 4 four digit code located on the front or 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:

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Signature Certificate
Document name: Authorization for Credit Card Use
lock iconUnique Document ID: 8188dd01068e7d5c05b29949690608bf87f096a5
Timestamp Audit
March 9, 2016 12:22 pm ESTAuthorization for Credit Card Use Uploaded by Michael McGee - info@drmichaelmcgee.com IP 102.129.145.244
November 8, 2021 6:01 pm EST Document owner mdm@wellmind.com has handed over this document to info@wellmind.com 2021-11-08 18:01:05 - 154.21.212.76
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This audit trail report provides a detailed record of the online activity and events recorded for this document.
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Audit Trail Serial# 61868449109170cd2cfa892b55bdc570