Client Last Name This is Card # on File 1 2 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: FOR EACH SERVICE AT THE TIME OF SERVICE provided to me by a service provider of TMG. FOR A MISSED APPOINTMENT at the rate of $85 if I cancel less than 24 hours in advance of my appointment. IF AND WHEN MY PAYMENT BALANCE BECOMES PAST DUE. My service provider will inform me about this charge. 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.Provider(s) being seen at TMG PLEASE COMPLETECredit Card Type MasterCard Visa American Express Discover Credit Card #Exp. Date Security Code Credit Card Holder’s Name on Card Email Address for Receipts ZIP Code for this account 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.Signature Date MM slash DD slash YYYY
