Payment Authorization Form
A problem was detected in the following Form. Submitting it could result in errors. Please contact the site administrator.
What would you like to do
New payment method
Update payment method
First Name
Last Name
Practice Name
Accounting Phone Number
Accounting Email
Payment information
Credit Card
ACH
Billing Address
City
State
Armed Forces America
Armed Forces
Armed Forces Pacific
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
New Hampshire
New Jersey
New Mexico
New York
Nevada
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Credit Cart Number
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
CSV
Bank Name
Account Type
Checking Account
Savings Account
Account Number
Routing Number
*
All credit card transactions will carry a processing fee of 3.5% per order.
I authorize Pipeline Medical to charge my credit card for the authorized amount. I understand that my information will be saved to file for future transactions on my account.
Signature
❌
Name
Date of Signature
Submit
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