LRADAC Payment Form

 You agree to provide LRADAC or associates acting on behalf of LRADAC with information that is truthful, accurate and complete. You are responsible for all activity and charges incurred by users of your credit card or other payment mechanisms.
Patient Name:

Patient Number or SSN:

Billing Zip Code:
Amount of Payment: $
Name on Credit Card:
Card Number:
Expiration Date:
Credit Card Security Code:
Recurring Automatic Payment:  Yes      No
Amount of Recurring Payment: $
Date of Recurring Payment:  1st of month
 15th of month
 I hereby authorize LRADAC to initiate automatic monthly payments to my account using the credit card listed above. Charges will occur monthly based on the date selected and will continue until the balance is paid in full or the agreement is terminated.
 
Further, I agree not to hold LRADAC responsible for any delay or denied transaction when processing my monthly payment. I understand it is my responsibility to have the funds in my account.

This agreement will remain in effect until LRADAC receives a written cancellation notice from the person authorizing this agreement.
(It may take up to 3 business days for your payment to be processed.)