Email Opt-In Form

If you receive your Annual Practice Fee invoice via email and use a credit card to pay through the “Pay Now” button, you are eligible for a $25 discount on your Annual Practice Fee! To receive an e-invoice, please complete the Email Opt-In Form below.

IMPORTANT: The $25 discount on your Annual Practice Fee is available ONLY if you opt to receive your invoice by email and pay by credit card through the embedded payment link on the emailed invoice.

Signing up is easy! You can fill out the form below online or print and complete our paper Email Opt-In Form HERE and submit it in any of the following ways:

Fax to (415) 651-8857
Email to billing_mdmgsf@protonmail.com
Mail to:
MERCY DOCTORS MEDICAL GROUP
One Shrader Street, Suite 640
San Francisco, CA 94117
Drop off your completed form at the Mercy Doctors Medical Group office.

First Name

Middle Initial

This is important for us to differentiate patients with similar names. If you do not have a middle initial, you may leave the space blank.

Last Name

Who is your provider?

I understand that by checking "I agree," I consent to receive invoices and limited electronic communications from Mercy Doctors Medical Group and its billing service, including but not limited to messages related to the Annual Practice Fee, general notices, requests for demographic or insurance clarification, and obtaining payment for balances due. Mercy Doctors Medical Group and its billing service will not share or sell my email and personal information except as required by law. A $25 discount is available if you opt to receive your invoice by email and pay by credit card through the embedded e-invoice link. The email invoice and pay by credit card discount is subject to change at any time at Mercy Doctors Medical Group’s discretion. I can opt out of receiving emails from Mercy Doctors at any time in writing by sending my name, address, and date of birth with the words “Opt Out” to billing_mdmgsf@protonmail.com.

I agree

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