Call Us

(951) 318-5396

Address

255 North D Street, Suite 400 San Bernardino, CA 92401

Mail

info@diligenceintegratedcare.com

Call Us

(951) 318-5396

Address

255 North D Street, Suite 400 San Bernardino, CA 92401

Mail

info@diligenceintegratedcare.com

Credit Card Collection

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Please fill this form to send it to your Physician

Credit/Debit Card Payment Consent Form

Financially Responsible Party:

Middle Name

Last Name

Name on Card if different:

I authorize Diligence Behavioral and Medical Integrated Healthcare, a Professional Nursing Corporation, dba Diligence Care Plus, to charge my card for professional services as follows:

Please Initial? | Any agreed-on session or service that is not paid for at the time service is rendered, unless other arrangements have been made for payment or I have a dispute concerning the service or payment for that service. No debits will be processed on my card until the dispute is resolved. I have been informed that all information provided here will never be shared with any other parties, and that it will be stored and transmitted according to strict encryption protocols and meet all federal HIPAA requirements for privacy.

Card Number #:

Date / Time

CVV/CVC/CSC/Security Code #:

Card Holder's Billing Address for Monthly Card Statements:

Street

City

State

Zip Code

*If I have questions about these charges, I agree to first contact my provider (Diligence Care Plus). I agree that I will not pursue a refund directly through my credit/debit card company, bank, or financial institution. If any of my actions yield a chargeback for any reason, I agree to pay any and all penalty fee(s) incurred by my provider. Please note that to be considered a valid card an HSA card must be tied to a funded account.

Card Holder Signature:

Sign Here

Date

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Address

Mail

Please fill this form to send it to your Physician

Credit/Debit Card Payment Consent Form

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