Credit Card Consent Form

CREDIT CARD ON FILE - ELECTRONIC CONSENT FORM

Patient First Name*:
Patient Last Name*:
Patient Date of Birth*: (mm/dd/yyyy)
Date of Request*: 8/22/2017

For your convenience, we have implemented a policy with enabled you to maintain your credit/debit card ("Card") information on file with us. With your consent, this information will be securely held to cover future charges and additional fees via Phreesia, which is PCI level 1 compliant.

Signing this consent in no way compromises your ability to dispute a charge or question your insurance company's determination of payment. Your insurance company ultimately determines the amount of money you may owe.

I herby authorize Peachtree Park Pediatrics to keep my Card information on file for payment of any and all charges for medical services for which I am financially responsible and that remain unpaid after applying insurance payments and adjustments, if any. Any balances greater than or equal to $300 per child per visit, a courtesy call will be made to the card holder to inform you the payment will be processed that day.

You will no longer receive a statement from our office. Instead of sending a statement, we will charge your credit card on file for the patient responsibility amount. This amount is determined by the explanation of benefits (EOB) form from your insurance company. For any balances greater than or equal to $300 per child, per visit, a courtesy call will be made to the card holder to inform that the payment will be processed that day. For all lesser amounts, we will charge your card and email you a receipt.

If my Card information changes for any reason, I will notify you. This consent shall remain in effect until terminated by parent/patient via written consent.

Guardian/Patient*:    Date*: (mm/dd/yyyy)
Phone*:
Address*:
City*:   State*:   Zip Code*:
Verification Code*: