After-Hours Care Appointments

Payment Plan

Credit Card Authorization Form (Payment Plan)

  • The Avance Care Payment Plan is available to patients who are not currently in a position to pay the full amount of their bill at once and have a credit or debit card. This plan is designed to give these patients an opportunity to pay off their balance at a rate of $50 every 30 days.On this plan, we require you to fill out the form below with your credit or debit card information. Every 30 days your card will be charged the arranged rate and an updated statement and receipt will be mailed out to you for your records. These 30 days give the patient an opportunity to prepare for the payment that will be charged to their card and this plan prevents your account from aging or forwarding to a collection agency. Collection agency reporting will result in further fees at a minimum of $40 and cause long term damage to your credit report.

    If your credit or debit card is denied it will be considered a missed payment and your account will immediately be taken off of our payment plan. This will cause your account to age and ultimately result in incurred fees and collection agency reporting.

    For the safety of your credit card information, Avance Care, P.A. has partnered with the industry leading PCI compliant payment gateway service, Authorize.Net (CyberSource Corporation, a wholly owned subsidiary of Visa.) The authorization is processed through a secured, encrypted channel and securely stored on Authorize.Net’s system using advanced tokenization security.Avance Care, P.A. does not store your credit card information on its electronic systems.

    Please complete the information below:

    Patient Information

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