Billing Zip Code definition
Examples of Billing Zip Code in a sentence
Patient(s) Name(s): _ _ Name on Account: Bank Name: Account #: Routing #: Card Type: MasterCard Visa Discover Amex Cardholder Name: Billing Zip Code: Card #: Security Code: Expiration: / I authorize Integrate Internal Medicine, P.C., to automatically bill the checking account or credit/debit card listed above, as specified.
Card Holder Name: Card Holder Signature: Card Number: Card Code: _ Billing Zip Code: Exp.
Patient Initials________ Credit Card #______________________________Exp Date:_________ Billing Zip Code:__________ FD Intials:_______ Cash patients must pay, in full, at the time of service.
Visa, MasterCard or Discover Card Card Number: Exp: CVV: Cardholder Name: Billing Zip Code (if different from above): I agree to the payment schedule for my Dental Assisting course with the NATIONAL DENTAL ACADEMY.
Visa Master Card Discover Name as it appears on Card: Billing Zip Code Credit/Debit Card #: Exp.
Signature: Date: Type of Card: Visa MC AmEx Card Number: Expiration Date: Security Code: Billing Zip Code:_ Your privacy is important to us.
Date: V Code: Deposit Pymt Amt: Date: _ Final Pymt Amt: Date: _ Billing Zip Code: _ Authorized Signature: BOOTH PACKAGES: One Undraped Table, Two Chairs and Wastebasket, Pipe & Drape, Booth Carpet or Stone Floor (depends on booth location), Booth Identification Sign, Directory Listing*, & Free postcard invitations Mail payments to: ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇, ▇▇▇ ▇▇▇-▇▇▇, ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇.
Text USPS Standard 4036 Customer Billing Zip Code The Customer's billing zip code (Zip+4 Code).
Card Number: Expiration Date: Card Type: VISA AMEX MC DISC Security Code: Billing Zip Code: Patient Signature Date I have chosen to receive mental health services in the form of psychiatric evaluation and medication management for myself and/or my child from Mindful Medicine of New England, LLC.
Name of Patient or Legal Guardian: Signature: Date: Type of Card: Visa MC Card Number: Expiration: Security Code: Billing Zip Code: Your privacy is important to us.