Get Credit Card Pre Authorization Form

Filling out the Credit Card Pre Authorization Form online is an essential step in ensuring timely payment for services provided by Island Kids Pediatrics. This guide provides clear and supportive instructions to help you navigate each component of the form effectively.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. In the first section, provide your name, authorizing Island Kids Pediatrics to keep your signature on file. This allows them to charge the selected credit card for any balances due at the time of service and afterward.
3. Select one of the credit card options: Visa, American Express, MasterCard, or Discover Card by checking the corresponding box.
4. Enter the names of your children who are patients of Island Kids Pediatrics in the designated area.
5. Fill in the cardholder's name and address, including the city, state, and ZIP code in the specified fields.
6. Input the credit card number, expiration date, and CVV2/CVC2/CID number in their respective fields.
7. Sign and date the form in the Cardholder Signature section.
8. If you are opting for ACH pre-authorization, provide your bank's name, branch, city, state, routing number, and account number in the ACH Pre-Authorization segment.
9. Print your name clearly, sign the ACH section, and date the form.
10. Once you have completed all sections of the form, save your changes, then you can download, print, or share the form as necessary.

Complete your Credit Card Pre Authorization Form online today to ensure smooth and timely billing.