PO Box 9004
Please fax this form to:
Please fill out the information below as it appears on your credit card. Please sign and date the bottom of this form. AOS will automatically charge your card each month.
CARD NUMBER: ________________________________________________
City: ____________________State: ________ Zip:___________
AOS BILL CODE :(_________________) as it appears on your AOS bill in bold type
Doctor’s Office Phone # (_______)__________________
By signing below, I authorize Automated Office Systems, (AOS) to charge the above credit card in the amount indicated above. I understand that by signing this document, I agree that this transaction shall be handled as a cash transaction and my recourse via the credit card company is hereby waived.
Cardholder’s Signature: ____________________________________ Date:_______________
***Please Fax or Send this form to Automated Office Systems (AOS) Fax# 516-396-5585***