Credit Card Payment Auth

Sunshine Center has implemented a new policy which enables you to maintain your credit card on file within our secure software system. In providing us with your credit card information, you are giving Tulsa Sunshine Center permission to automatically charge your credit card on file for your co-pay at time of service.

Sunshine Center will only charge your credit card for individual payments relative to a single visit (Co-Pay , Deductable Payment....etc). Any other charges that occure due to insurance denial...etc will appear on your monthly statement for you to review and discuss with our billing team.

Child's First Name

Child's Last Name

Child's Date Of Birth

Credit Card Number

Card Holder Name

Visa

Mastercard

Discover

AMEX

Exp. Date

Security Code

I hereby authorize any of the above stated amounts be applied to my credit card :

Signature of Card Holder :

( Draw your Signature below in the box with your finger or mouse )