TMG uses a secure electronic health record (EHR) payment system. Your provider will enter your credit card information into this system with your permission and charge your account through it.
By signing below I authorize TMG to use the credit card information below to charge my credit card using an on-line system for the following purposes:
I acknowledge that I will be receiving an email with a receipt for the payment, as well as an e-mail with an itemized statement with appropriate information needed to submit to my insurance company and/or for tax purposes.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.