EFTA00314075.pdf

Weed Cornell Physician Organization Wei!I Med;r2( Collage of Cornell University CREDIT CARD PAYMENT AUTHORIZATION FORM Cardholder Fax Number: Department Fax Number Department Contact: 41/11/C 4 4 , 77Oi £lp-r. aSt-volIP Date: Please be advised that in order to process your payment request the following form must be completed thOreUgNy. Please print clearly OP5-reo--1 -YE -6 \1 (CARDHOLDER LAST NAME) (CARDHOLDER FIRST NAME) wEt11 CORNELL MEDICAL COLLEGE OF CORNELL UNIVERSITY authorize /.7,9gASI Marl "no within (PROVIDER NAME) z..,rectcc:6.fri (DEPARTMENT NAME) thane my A M ER l CA n1 EAPPStSS credit card account number (TYPE OF CREDIT CARD) with an expiration date (-la in the amount of S (DOLLAR AMOUNT) to EP3-r . E-•-1 .to H (PATIENTS LAST NAME; (FIRST NAME) for IOX aotountrinvoice number. (RELATIONSHIP TO THE PATIENT. if Met that card herder) (TO BE ENTERED BY DEPARTMENT) Please provide the CV2JAVS number that appea number 9 (2`f . *(Note: This number i Cardholder Signatu Date: OPt Cardholder Daytime Phone Number: .0 back of it card after account ordo t ocess you payment) Visa. MasterCard • Last 3 dicks on back c( card on Authorization Signature Strip American Express • Last 4 akin on Pax, middle right nand side of card (not embossed) r For itgernelPutpoSes only. Select one: Patient Receipts imernarioimi Patients Corpoeare neakn Ptrystcals w.C.P.O. Finance °rice Credit Card Poitcy and Procedures EFTA00314075