Billing

Paperless Billing Form

Invoices will be emailed at thebeginning of the month following the previous month’s services and automatically billed to your debit/creditcard 14 days later. If the card becomes inactive at any time, reminders will be sent. A late payment fee will be applied to accounts more than 60 days past due to cover the costs of pre-collections proceedings. It is your responsibility to update the email address on file when needed to avoid late fees and pre-collections proceedings due to non-receipt. (Per federal law it is a requirement that you be aware: email confidentiality cannot be guaranteed.) Please complete the following 4 steps (clients currently enrolled in autobilling may complete items 1 & 2 only for verification purposes):

1) Patient’sName(s):__________________________________________________ 2) Email address of the person who is financially responsible:

      __________________________________________________________________

Visa, Mastercard, Discover, and American Express are accepted. Once entered, stored, and encrypted in the accounting system, Diablo Hills Accounting will safely discard the information on this form. Payee on your billing statement will appear as: Raymond Hearey, M.D.

1. 3)  Debit/Credit card information:

   Credit Card Number:____________________________________________________ Name on Credit Card: ___________________________________________________ Card Expiration Date: ___________________________________________________ 3 or 4-digit CVV Code (on back of card): ___________________________________ Credit Card Billing Address: _____________________________________________ _____________________________________________________________________

2. 4)  I authorize Dr. Hearey to bill my debit/credit card every month for services rendered:

   _____________________________________________________________________ Authorized Signature Date