Credit Card Payment Authorization Form
Personal information
*(Name on credit card)
Billing Address
(Street or PO Box)
(City)
(State)
(Postal Code)
(Country)
*E-mail Address(For Confirmation)
Credit Card Information
Credit Card Information(check one): Visa Discover MasterCard American Express
/
Expiration Date
(month/date)
Credit Card Validation

3-digit code for Visa, MC, and Discover, on back of card
4-digit code for American Express on front of card
I authorize AnsweringCare to charge my credit card $99.00 per month for each Doctor signed up.
(Authorizing Signature)
(Date)
Please fax your completed form to 760.269.3519 , For security reasons, completed versions of this form cannot be sent via email.
Amount: