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CAHPS® Clinician & Group

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I authorize Fields Research to make recurring charges to my Credit/Debit card listed above, and if necessary, to initiate adjustements for any trasactions credited or debited in error. This authority will remain in effect until Fields Research has received written notification from me to cancel it. Notice must be received by Fields Research within seven days prior to the recurring charge date in order to cancel the next payment. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

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If you have any questions please contact the FieldsResearch CG-CAHPS® Team (513) 821-6266

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