WCP - Payment Plan Authorization Form

WCP - Payment Plan Authorization Form

By completing and signing this form, I am authorizing Whole Child Pediatrics to charge the payment plan amount monthly as indicated on the Payment Plan Authorization Form from the credit/debit card account I designate when I electronically sign this form via the Whole Child Pediatrics website by providing the payment plan authorization number listed at the top of this page, credit/debit card information and signature. I am also aware if the primary card is a Flexible Spending Account card (FSA) or Health Reimbursement Account card (HRA) I am required to leave an additional card on file, to be used, in the event the charges decline on the primary card.