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

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I authorize Muenster Memorial Hospital to process the above payment of $. I also authorize Muenster Memorial Hospital 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 Muenster Memorial Hospital prior to the payment date.

I authorize Muenster Memorial Hospital to process the payments as outlined in the payment schedule. I also authorize Muenster Memorial Hospital 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 Muenster Memorial Hospital prior to the payment date.

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