I authorize Premier Pediatric Therapy Source, Inc. to charge the above credit card to process payments for services rendered.
I understand my card will be charged on the payment due date for the amount indicated on each monthly invoice.
I agree that all the information provided below is accurate and complete. By signing below, I authorize that my credit card be charged for applicable co-pays, deductibles, monthly cap amounts (PIE program) and/or uncovered services by your insurance provided by Premier Pediatric Therapy Source, Inc.
I understand that I can terminate this agreement at any time with a 30 day written notification.