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180 Medical Recurring Payment Form
"
*
" indicates required fields
Client Name
*
180 Medical Account Number
*
Payment Method on File
Checking / Savings Account
Visa
MasterCard
American Express
Discover
Last 4 digits of account number
Please enter only four digits, not the full number.
Select an Option
*
I authorize all deductible and coinsurance amounts be charged
I authorize up to the amount specified below to be charged per month
Amount per Month Authorized
If you chose to allow up to a certain dollar amount each month
Preferred Charge Day
MM slash DD slash YYYY
The date you prefer to have your payment method on file charged (if you have no preference, leave blank)
Email
Please include your email address if you request receipt of payment
Receipt Requested
Yes, I request a receipt
No
Authorization for Recurring Payments
*
I authorize 180 Medical to keep my signature on file and to charge the outstanding balance for the account listed to my provided credit card or checking/savings account.
Signature
*
Date
*
MM slash DD slash YYYY
Phone
This field is for validation purposes and should be left unchanged.
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