Credit Card on File Agreement (optional)On File Agreement • February 18th, 2020
We have implemented a policy which enables you to maintain your credit card information securely on file with Pima Dermatology, PC. In providing us with your credit card information, you are giving Pima Dermatology, PC permission to automatically charge your credit card on file [for the patient you have listed on this form]
Credit Card on File AgreementOn File Agreement • September 13th, 2021
Providing your credit card information allows the convenience of payment for your services. In the event of a missed or cancelled appointment (per the cancellation policy), the card on file will be charged. By signing this form, you give The Centered Life permission to charge your credit card for the purpose of co-pays or any outstanding balances.
Credit Card on File AgreementOn File Agreement • October 27th, 2021
West County Spine & Joint Chiropractic Clinic is committed to reducing waste and inefficiency and making our check-out process as simple and easy as possible, as well as minimizing the contact you have with staff at each visit. Starting November 1st, 2021, we are now requesting that you provide a credit card on file with our office. Your card will be charged on each date of treatment and may be used to pay outstanding balances. Payments are processed through a HIPAA-compliant, secure practice management software EZBis and Payment Innovators. We will scan your card with a card reader and your payment information is stored on Payment Innovator’s secure servers for future transactions. Office personnel does not have access to your card. For your protection, only the last 4 digits of your card will show in our system.
Credit Card on File AgreementOn File Agreement • March 2nd, 2020
We can securely maintain your credit card information on file with our merchant services. This information will be securely held until your insurance provider has paid their portion of your bill or if payment has not been received from the insurance provider in 60 days. At that time, any balance, which you owe to our office for services that have already been rendered, will be charged to your credit card and a receipt will be sent to you.
Credit Card on File AgreementOn File Agreement • January 24th, 2023
This does not compromise your ability to dispute a charge or question your insurance company’s determination of payment. If there is a discrepancy that you would like to dispute, please contact your insurance company.
Credit Card on File AgreementOn File Agreement • May 2nd, 2022
You are giving Pure Dermatology and Skin Surgery Center permission to automatically charge your credit card on file for your outstanding balance or any other patient(s) balance you have listed on this form at time of service.
Credit Card on File AgreementOn File Agreement • November 29th, 2018
You are giving Pure Dermatology and Skin Surgery Center permission to automatically charge your credit card on file for your outstanding balance or any other patient(s) balance you have listed on this form at time of service.
Credit Card on File AgreementOn File Agreement • January 13th, 2020
Linda C Wang, MD, LLC has implemented a new credit card policy, similar to other businesses such as a hotel, car rental agency or attorney’s office. Our policy enables you to maintain your credit card information securely on file, and to give us permission to automatically charge your credit card on file for any balance that may be due on your account. This agreement will remain in effect until the expiration of the credit card account. You may revoke this agreement at any time by submitting a written request.
PATIENT CREDIT CARD ON FILE AGREEMENTOn File Agreement • August 28th, 2020
We have implemented a policy which enables you to maintain your credit card information securely on file. In providing us with your credit card information, you are giving Alexandria Associates In Dermatology permission to automatically charge your credit card on file for your co-pay [or any other patient(s) you have listed on this form] at the time of service. By signing this, you authorize this agreement will remain in effect until the expiration of the credit card account and that you may revoke this form at any time by submitting a written request.
Credit Card on File AgreementOn File Agreement • October 25th, 2021
o I, authorize Moore Foot & Ankle Specialists, PA to charge my credit card for the following reasons: Co-pays or co-insurance, cancel or no-show fees, self-pay items not covered by insurance, and any other item and/or service that I give verbal or written permission for.
Credit Card on File AgreementOn File Agreement • May 28th, 2021
In an effort to improve patient service and office efficiency, ABC Pediatrics, Ltd. has implemented a credit card on file policy. Much like many other businesses such as a hotel or car rental agency, attorney, etc. we have a similar policy where we ask for a credit card which may be used later to pay any balance that may be due on your bill. Copays are due at the time of service.
Credit Card on File AgreementOn File Agreement • May 12th, 2020
ECO-HEALTH Therapy has implemented a new credit card policy. Much like many other businesses such as a hotel or car rental agency, attorneys, etc. we now have a similar policy where we ask for a credit card which may be used later to pay any balance that may be due on your bill.
Credit Card on File AgreementOn File Agreement • December 16th, 2020
We have implemented a new, convenient payment policy using Credit Card on File, effective at Bosco E. Noronha, M.D., P.C. As you are aware, the current state of healthcare in our market has resulted in significant changes in insurance policies, co-pays, deductibles and premiums. Unfortunately, a great deal of the financial burden now falls on the patient as a result. There are insurance plans that require deductibles and copayments in amounts unknown to you, or to us, at the time of your visit. ALL PATIENTS will be asked for a credit card at the time you check in, and this information will be held securely. The amount that we will charge to the credit card on file will be the financial responsibility that the insurance company requires you to pay.
