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.
Email*
Is this an HSA/FSA/Flex Spending Account?
- Yes
- No
Patient's Full Name*
First Last
Patient's Date of Birth
Full name as it appears on the card*
Credit Card Number except the last 4 digits*
Last 4 digits of Credit Card Number*
Expiration Date*
CVV*
Billing Zip Code*
Signer's Name*
First Last
Please type in the name of the patient or the guardian, if patient is under 18 years of age, to sign the document.

Patients

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

Last 4 Digits of Credit Card #:

Is this an HSA/FSA/Flex Spending Account?

Leave this empty:

Your legal name

Your email address