"Where Compassion, Caring and Dedication Come First"

I hereby authorize TLC Pediatrics of Amarillo, PA to retain my credit card information and authorization noted below, and to charge the credit card for any deductibles, coinsurances, copayments or other services rendered to/for the persons listed below. Charges are to be entered only for those balances due that are not covered by insurance. A copy of the credit card receipt and an account statement will be sent to the patient/guarantor with each charge.