Credit Card on File Authorization Name Initials SignatureDate MM slash DD slash YYYY CREDIT CARD NUMBER Expiration Date CVV Code Card Holder's Printed Name SignatureDate MM slash DD slash YYYY Billing Address Associated with Card on FilePatient Name Date of Birth MM slash DD slash YYYY Card Holder's relation to patient Billing Address PhoneCity StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Scanned date: Staff initials: System "Alert" added: Δ