Mobile Credit Card Authorization Form

By signing this form, you agree that your credit card will be charged for the balance of the approved service that are rendered on the day of service. The patient/guardian/durable power of attorney/responsible party approves services verbally or written prior to services.

You will receive a statement of services and credit card charge via email, fax, or mail.

I authorize DIVA Mobile to charge my credit card an amount due for the services received. In case there are any problems with my credit card, I agree to provide alternative payment. If not, I agree to pay collection and attorney fee.

Credit Card Information

My Contact Information