Credit Card Information

By providing your credit card information below, you agree to all of POST Physical Therapy's Credit Card on File Policy and are aware that your valid credit/debit card number will be securely on-file in your account.

You understand that POST Physical Therapy will automatically charge your credit card for all co-payments, deductibles, coinsurances and cancellation fees. Missed or cancelled appointments without 24-hour notice will be charged a $50 fee at the time of the appointment. 

If the credit card that you give today changes, expires, or is denied for any reason, then please immediately contact POST Physical Therapy with a new, valid credit card.

Thank you,

POST

  • Please note that we do not accept AMEX.

  • Please type in the name of the patient or the guardian, if patient is under 18 years of age, to sign the document.

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Credit Card Information


By providing your credit card information, you agree to all of POST Physical Therapy's Credit Card on File Policy and are aware that your valid credit/debit card number will be securely on-file in your account.

You understand that POST Physical Therapy will automatically charge your credit card for all co-payments and cancellation fees and any deductible, coinsurance, or other statement balances. Missed or canceled appointments without 24-hour notice will be charged a cancellation fee at the time of the appointment.  You authorize POST Physical Therapy to securely store your credit card information, and only charge it should you have a copayment, cancellation fee, deductible, co-insurance, an outstanding balance, or any leftover balance from processed claims.

If the credit card that you give today changes, expires, or is denied for any reason, then please immediately contact POST Physical Therapy with a new, valid credit card.

Thank you,

POST





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Signed by POST PT Luke Ferdinands
Signed On: September 20, 2021


Signature Certificate
Document name: Credit Card Information
lock iconUnique Document ID: c7b7bb581920324100ea40dd216820d1d2cc8833
Timestamp Audit
December 10, 2018 3:31 pm EDTCredit Card Information Uploaded by POST PT Luke Ferdinands - info@postpt.com IP 173.9.65.41