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 Date: £lp-r. aSt -volIP 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 authorize /.7, 9gASI Marl "no within (CARDHOLDER LAST NAME) (CARDHOLDER FIRST NAME) (PROVIDER NAME) wEt11 CORNELL MEDICAL COLLEGE OF CORNELL UNIVERSITY z..,rectcc:6.fri .to (DEPARTMENT NAME) thane my A M ER l CA n1 EAPPStSS (TYPE OF CREDIT CARD) credit card account number H with an expiration date (-la in the amount of S (DOLLAR AMOUNT) to EP3-r . E-•-1 (PATIENTS LAST NAME; (FIRST NAME) (RELATIONSHIP TO THE PATIENT. if Met that card herder) for IOX aotountrinvoice number. (TO BE ENTERED BY DEPARTMENT) Please provide the CV2JAVS number that appea .0 back of it card after account number 9 (2`f . *(Note: This number i ordo t ocess you payment) Cardholder Signatu Date: OPt Cardholder Daytime Phone Number: 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