If you wish to have us submit any outstanding balance to your credit card, please complete the following and mail it to our Honesdale office.

I hereby grant authorization to PPNP the use of my credit card for the unpaid balance of $ ____________.

I understand this authorization is for this transaction only and that under no circumstances will the card be used again without my written or verbal authorization.

My credit card information is as follows:

Credit Card No. _______________________________________________Expiration Date: _______/__________

MasterCard/Visa
(circle one)

Cardholder’s name as it appears on Credit Card: ______________________

Authorized Signature: ________________________________________________

Date: __________________

Patient Name: ______________________________________________________

Daytime Telephone Number: (_________) - ____________________________

Sign, date and mail completed form to:
Pediatric Practices of NEPA
Billing Department
1837 Fair Avenue
Honesdale, PA 18431