Payment Authorization
This information is in regards to how you intend to pay the provider bill and the H.H.C. Group service fee. H.H.C. Group will only charge your account if we obtain savings for you.

Credit Card Type *
Credit Card Number *
Expires on *
CVV2 *
Name "exactly" as it appears on card *
Street Address
(where card is billed)		 *
Ste/Apt
City *
State *
Zip Code
(where card is billed)		 *
e.g. 12345
Amount of
Pre-Authorization		 *
Comments
* Required


H.H.C. Group • 9420 Key West Avenue, Suite 330, Rockville, MD 20850
 consumer@hhcgroup.com
URAC




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