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Account Information

Account Number on Statement

Patient First & Last Name

Payment Information

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Card Holder Last Name

Card number

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Payment ($)

Pay in full today 4 equal payments 3 equal payments 2 equal payments

You are agreeing to pay $ plus a 0.00 of $ (%) for a Total of $.

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I authorize CASCADE EMERGENCY PHYSICIANS to process the above payment of $. I also authorize CASCADE EMERGENCY PHYSICIANS to store this information in compliance with payment processing regulations and to charge the card listed above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact CASCADE EMERGENCY PHYSICIANS prior to the payment date.

I authorize CASCADE EMERGENCY PHYSICIANS to process the payments as outlined in the payment schedule. I also authorize CASCADE EMERGENCY PHYSICIANS to store this information in compliance with payment processing regulations and to charge the card above for future payments in accordance with their terms. I understand that to make any changes to this authorization I must contact CASCADE EMERGENCY PHYSICIANS prior to the payment date.

Please include your patient account number which is on your billing statement, when submitting your payment.

If you have any questions please contact our office at 1-800-225-0953. Thank you for using our online convenient payment center.

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