One-Time Credit Card Payment Authorization Form

Medversant Technologies, LLC | 355 South Grand Avenue, Suite 1700 | Los Angeles, California 90071 | One-Time Credit Card Payment Authorization Form Please sign and complete this form to authorize Medversant Technologies, LLC to make a One-Time debit to your Credit card, as listed below. By signing this form you give Medversant permission to debit your account for the amount indicated on or after the indicated date. Please fax the completed form to (877) 303-4078. Please complete the information be low: I, _____ , authorize Medversant Technologies, LLC to charge my Credit card (Full name ) account, as indicated below, for _____ on or after _____. This Payment is (Amount) (Date) for _____ for the Provider,_____. (Description of goods/services) (Name of Provider) Billing Address _____ Phone#_____ City, State, Zip _____ Fax # _____ Email _____ Checking / Savings Account Credit Card / Debit Card Name on Account _____ Bank Name _____ Account Number _____ Bank Routing # _____ Bank City / State _____ Services Offered: 1.

Washington Practitioner Application – July 2013 Page 1 of 13 PRACTITIONER NAME: Modification to the wording or format of the Washington Practitioner Application may invalidate the application.

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