PlayRx - Card on File Agreement-PlayRx

PlayRx - Card on File Agreement

Thank you for the opportunity to meet your child's developmental needs. PlayRx runs cards once per week, the week following services.

Child’s first and last name

First Name

Last Name

I, the guardian identified above, authorize PlayRx to file my card information and run payment of services rendered.

Card Information:

Name on Card:

Card Number:

Expiration Date:

Security Code:

Billing Zip code:

Email

PlayRx will only submit charges for services provided at the rates agreed upon or dictated by patient obligation of deductibles, co-pays, or co-insurance. You will receive a BloomText receipt from PlayRx immediately following transaction.

Date Signed:

Representative of patient name:

Representative of Patient Signature:

*

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