EFTA02319166.pdf

Memorial Sloan-Kettering Cancer Center The Bobst International Center 160 East 53' Street, 1Ith Floor New York, NY 10022 Credit Card Payment Authorization Office Facsimile Office Telephone (212)639-4938 212-639-4900 By signing below, I hereby authorize the Memorial Sloan-Kettering to charge my Credit Card for any physician visits, procedures, and tests, treatment modalities and/or services that may be provided to me at Memorial Sloan-Kettering Cancer Center. We will require approval for each charge to the credit card. Patient Account Number Patient Name (Last, First) Payer Zip Code 10021 Payer E-Mail Relationship to Patient friend Payment Amount Indicate type ofcredit card to be charged (We do not accept Debit Cards) IRl American Express ❑ Mastercard ❑ Visa ❑ Diners Club ❑ Discover Credit Card Number Exp. Date CVN Cardholder's Information: Me Address where the credit card statements are mailed) Name_M Signature Street 9 E 71g St. City New York, Country USA PostalCodc 10021 Telephone if Date I 2/28/1 2 Credit Card Authorization may be faxed to The Bobs( International Center at (212)639-4938 Please call 212-6394900 to say you have faxed this font. Poymeat AsiborImiloa Form Credit Card (revised 11/9/10) EFTA_R1_01226752 EFTA02319166