Avance Primary Care | Avance Primary Care - Credit Card Authorization Cancellation Form

Credit Card Authorization Cancellation Form

Patient Information
First Name*
Middle Initial
Last Name*
Date of Birth*

MM

DD

YYYY
Sex Assigned at Birth:*
Account No:
Cardholder Information
First Name*
Last Name*
Address*
City*
State*
ZIP Code*
Cardholder Phone*

(Format: xxx-xxx-xxxx only)
I request cancellation of credit card authorization provided to Avance Care, P.A. for the above named patient.
Patient Signature (or legal guardian if minor patient)*
Print Name*
Date*
Please provide your email if you want to receive a copy of this completed form. You can also receive a hard copy by asking one of our team members.
Email