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Credit Card Authorizations with your signatureMay be faxed to the Memorial Sloan-Kettering International Center at 212.639-4938
FOR YOUR OWN PROTECTION – DO NOT EMAIL CREDIT CARD INFORMATION
Memorial Sloan-Kettering Cancer Center Physician
By signing below, I hereby authorize the Memorial Sloan-Kettering Cancer Center to charge my Credit Card for any physician visits, procedures, and tests, treatment modalities and/or services that may be provided at Memorial Sloan-Kettering Cancer Center.
For your protection, Credit Card Information (your Account Number/Signature) is not kept on file at the International Center. Therefore, we will request your signatory approval for each charge to your credit card. Indicate type of credit card to be charged (We do not accept Debit Cards)
Credit Card Number: _____________________________________ Expiration Date: ____/____/____ CVN Number: _______________________________________________
Name (as it appears on the credit card): ____________________________ Today’s Date: ____/____/____
Signature of authorized cardholder: _____________________________________________________________
Patient Name: Artem Kuznetsov Medical Record Number: 35437088
Comment: For Physician Related Services noted on Deposit Letter of June 26, 2014.
Amount: $ 54,000
Street: ___________________________________________________________________________________________________________
City: ______________________________________________________ Country: ___________________________________________
Postcode: ________________________________________________________________________________________________________
Credit Card Authorizations with your signature May be faxed to the Memorial Sloan-Kettering International Center at 212.639-4938
FOR YOUR OWN PROTECTION – DO NOT EMAIL CREDIT CARD INFORMATION
Memorial Sloan-Kettering Cancer Center
· Bank Wire Transfers should be directed as follows:
Bank: JP Morgan Chase Park Avenue New York, New York 10017 ABA# 021000021 Account: Memorial Sloan-Kettering Cancer Center Acct. # 134687132 (Swift Code: CHASUS33)
Official “Confirmation” (from Chase) of Wire Transfer must be received at least 72 hours prior to scheduled services at Memorial. · Please request that your bank include the following information on the Transfer: · Patient’s Full Name: · And Patient’s Medical Record Number (if available): · Please notify the MSK International Center staff by Fax when the funds have been wired. Let us know the Name of the Sending Bank, their address, the Account Number as well as the Reference Number. · Take note, any Administrative Processing Fees charged to MSK by your Bank will be debited to your account.
Payment Auth Form Bank Wire Transfer Revised 10 -02
Date: 2015-12-11; view: 599
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PBD ____