Weili Corneil Physician Organization Weill Medical Collage of Cornell University CREDIT CARD PAYMENT AUTHORIZATION FORM { Cardholder Fax Number: Ee Department Fax Number rm ¥ |Anre 2 er108 eer as auir Please be advised that in order to process your payment request the following form must be completed thoroughly. = “Please print clearly ae aa 7 4 EPs TE}-I we EFL FREY ____ authorize DARA “AO UE, (PD within (CARDHOLDER LAST NAME} (CARDHOLDER FIRST NAME) (PROVIDER NAME) to WEILL CORNELL MEDICAL COLLEGE OF CORNELL UNIVERSITY eRCLOGS as (OEPARTMENT NAME) charge my AM ER 1c A ni EYE RE 3S credit card account number. i a (TYPE OF CREDIT CARD) with an expiration date G/S1 in the amount of $ =~ (OOLLAR AMOUNT) ow EPsten | Ferree ee <7 aan (PATIENT'S LAST NAME} {FIRST NAME} (RELATIONSHIP TO THE PATIENT, if other that.card hoider} | for |1OX accounvinvoice number. | | {TO BE ENTERED BY DEPARTMENT) Please provide the CV2/AVS number that appea: Mit card after account number__ GO4 9__. *(Note: This number i pfocess you payment) Cardholder Signatur Date: Cardholder Daytime Phone Number: Visa, MasterCard * Last 3 digits on back of card on Authorization Signature Strip American Express * Last 4 digits on front, middle right hand side of card (not embossed) fhe 8 ey eee ee | Select one: Patient Receipts international Patients Corporate Health Physicals - W.C.P.O. Finance Office Credit Card Policy and Procedures EFTA00314075