NPIP – John Naus, MD PA

Please submit your payment information to secure your appointment.

Name (Patient's Name) *

First

Last

Phone *

Please enter your appointment date and time that we are charging. *

Card type (VISA/Master Card/ect.) *

Name as it appears on your card *

Credit Card Number *

Expiration Date *

Security Code *

Please check all that apply, but at least one to be charged/updated. (Itemized receipts available upon written request.- Message us on the web: johnnausmdpa.com, see "MESSAGES" tab) *

Charges due for my upcoming visit. (Please enter your appointment time and date above)
Other - for any "other" needs like: outstanding balances/letters/forms/other charges ect.

I authorize John Naus MD PA to charge my credit card for the charges due at the time of my new patient visit and/or the other charges I have incurred. All charges will be billed and collected as dictated by the agreed upon treatment contract. *

I have read and agree with this statement.

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