Memorial Sloan-Kettering Cancer Center The Bobst International Center 160 East 53™ Street, 11'" Floor New York, NY 10022 Credit Card Payment Authorization Office Facsimile Office Telephone Le a By signing below, I hereby authorize the Memorial Sloan-Kettering to charge my Credit Card for any physician visits, procedures, and tests, treatment modalities and/or services that may be provided to me at Memorial Sloan-Kettering Cancer Center. We will require approval for each charge to the credit card. Patient Account Number __ 35367668 Patient Name (Last, First) Po Payer Zip Code__ 10021 Payer Relationship to Patient friend Indicate type of credit card to be charged (We do not accept Debit Cards) a American Express O Mastercard L] Visa im Diners Club im Discover Credit Card Number Pe (Cardholder’s Information: (The Address where the credit card statements are mailed) a Signature Street 9ETI* St City New York, NY Country USA PostalCode 10021 Telephone # P| Date 12/28/12 Credit Card Authorization may be faxed to The Bobst International Center at Please call | to say you have faxed this form. Payment Authorization Form Credit Card (revised 11/9/10) EFTA00522360