Payment Authorization Form
Please complete all the fields in the form below. You may cancel the authorization at any time by contacting. The authorization will remain in effect until cancelled.
Note: 3% processing fee will be applied on all transaction using your credit card.
I, authorize VA Healthcare Transportation LLC to charge my credit card above for agreed upon purchases. I understand that my information will saved to file for future transaction on my account.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Payment Authorization Form
Agree & Sign