Credit Card On File Policy Form

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CREDIT CARD ON FILE POLICY
At [Name of Practice], we require keeping your credit or debit card on file as a
convenient method of payment for the portion of services that your insurance doesn’t
cover, but for which you are liable. Without this authorization, a billing fee of [$X] will be
added to your account for any balances that we must attempt to collect through mailing
monthly statement. Furthermore, an "outstanding balance" charge of 1.5 percent of the
total bill will charge for each month that the bill remains unpaid.
Your credit card information is kept confidential and secure and payments to your card
are processed only after the claim has been filed and processed by your insurer, and the
insurance portion of the claim has paid and posted to the account.
I authorize [Practice Name] to charge the portion of my bill that is my financial
responsibility to the following credit or debit card:
☐ Amex
☐ Visa
☐ Mastercard
☐ Discover
Credit Card Number ___________________________________________________
Expiration Date
_____ / _____ / _____
Cardholder Name
___________________________________________________
Signature
___________________________________________________
Billing Address
___________________________________________________
City _____________________ State_______ Zip ___________
(we), the undersigned, authorize
I
and request [practice name] to charge my credit
card, indicated above, for balances due for services rendered that my insurance
company identifies as my financial responsibility.
This authorization relates to all payments not covered by my insurance company for
services provided to me by [practice name].
This authorization will remain in effect until I (we) cancel this authorization. To cancel, I
(we) must give a 60 day notification to [practice name] in writing and the account must
be in good standing.
Patient Name (Print): _____________________________________________
Patient Signature:
_____________________________________________
Date:
_____ / _____ / _____

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