690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

PATIENT CREDIT CARD ON FILE FOR PAYMENT

    Is this a HSA/ FSA card? YN

PLEASE READ THE FOLLOWING BEFORE SIGNING:

I have provided Advanced Therapy Solutions my credit card information to keep on file for future use. This means I am authorizing Advanced Therapy Solutions to charge my credit card by the 20th day of each month for the previous month’s dates of service rendered and/or past due balances. A receipt for payment will be emailed. For appointment that fall after 4:00 PM or on the weekend, it is ATS’ policy that a credit card must be on file for co-pay, co-insurance or payment responsibilities.

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