Patient, Facility, and Organization Payment Authorization. 

Make single or partial payments on multiple invoices, even if you do not have the invoice number;

  • Enter the invoice(s) number(s), and or patient name with date of birth, we will match up the payment to account prior to charging the card to ensure it's accurate and not overpaid. 

  • Facilities and other organizations, enter the invoice(s) number(s), and or patient name with date of birth, AND OR just your facility name with address or other information in the boxes provided, we will match up the payment to account prior to charging the card to ensure it's accurate and not overpaid. 

 

Payment Authorization Form 

 

Cardholder Information 

Card Type

1920 E. Katella Ave. Suite K. Orange Ca. 92867
             Scheduling 714-997-4262 Billing 714-627-9195 Fax 888-689-9070