Payment Authorization | Insight Wellness Center

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Please complete all required fields. Once completed your information will be submitted securely to our Billing Department Manager, Victoria House. This information will be used to create your StoredPay Account and a separate email (from [email protected] ) will be forthcoming to confirm your authorization to use this payment information to process balances due for Copays, Deductibles and Cash balances due per your rate agreement.

I am a

Today's Date

Name*

Address*

Phone Number*

Other Phone

Email*

Select Credit Card or Account Checking Options:*

CREDIT CARD

ACCOUNT CHECKING

Credit Card Information

Cardholder Name*

Card Number*

Expiration Date*

Billing Zip Code*

Signature of Responsible Party (use mouse or finger to sign)*

Bank Account Information

Bank Account Name

Routing Number*

Account Number*

I agree to these terms: Signature of Responsible Party (use mouse or finger to sign)*

Check if you are filling this form

Check if you are filling this form on behalf of someone else and you have the consent from the party in initiating this inquiry to sign on their behalf.

Full Name*

Phone*

Email*

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If someone else

If someone else, besides the patient, is completing this form and is financially responsible for any balance due, please add your contact info here:

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Name of Responsible Party if other than Patient named above

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Name of Responsible Party if other than Patient named above

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Address

Please direct any future billing questions to Victoria House, Billing Manager via email [email protected] Or Call (530) 474-6094

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