Credit Card on File AgreementCredit Card on File Agreement • September 29th, 2017
Lam Dermatology and Associates has a credit card on file requirement. Recent changes in healthcare markets and payment processes have altered insurance coverages to shift more of the cost of care to our patients. The credit card on file policy is a convenient method to pay for the portion of services that are deemed patient’s responsibility, such as copay, deductible and co-insurance.
Turning PointCredit Card on File Agreement • April 7th, 2017
This form authorizes Turning Point Center for Psychological and Family Growth, LLC (Turning Point Center) to retain your valid credit card number on file. The form is confidential and only authorized staff will have access to your information.
Credit Card on File AgreementCredit Card on File Agreement • December 23rd, 2021
We have implemented a policy which enables you to maintain your credit card information securely on file with Richmond Creative Counseling (RCC). In providing us with your credit card information, you are giving RCC permission to automatically charge your credit card on file for your (or any other patient(s) you have listed on this form) co-pays/ co-insurance, outstanding balances, missed/ canceled appointment fees, services, and/or products.
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • March 29th, 2023
Triangle Family Dentistry is implementing a new credit card on file policy effective February 2023. Like many other dental and medical practices, we have adopted a similar policy. We kindly request our patient’s guardian/guarantor provide a credit card which will be used to pay a balance. Co-pays are still due at the time of service. Your credit card information will be obtained and kept securely on file.
Credit Card on File Agreement (optional)Credit Card 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 AGREEMENTCredit Card on File Agreement • March 31st, 2014
We have an optional system allowing us to maintain your Credit Card information securely on file which would be accessed only under the terms you specify below. This is completely optional and for your convenience regarding payment of services rendered.
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • November 7th, 2020
Outstanding Bills: It is not our policy to carry balances with our clients. Payment is due at the time of service. Unless prior arrangements have been made, if for any reason you should have a balance that is sixty (60) days past due, we will automatically charge the balance to your credit card on file.
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • August 28th, 2020
Your credit card on file will be used for all charges incurred for services at DeBalzo, Elgudin, Levine, Risen LLC. If covered by insurance payments to your credit card are processed only after the claim has been filed and processed by your insurer, and the insurance portion of the claim has been paid and posted to the account.
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • August 29th, 2024
This form authorizes Center for Behavioral Wellness to retain your valid credit card number on file. This form is confidential and only authorized staff will have access to your information. All credit card information will be stored and processed through a
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • November 9th, 2015
Credit Card on File AgreementCredit Card on 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 AgreementCredit Card on File Agreement • November 7th, 2020
Credit Card on File AgreementCredit Card on File Agreement • March 27th, 2023
Hinsdale Asthma and Allergy Center 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.
RALUCA RADULESCU, M.D.Credit Card on File Agreement • May 31st, 2023
This agreement is required – if you choose to decline this authorization or do not maintain a valid and current credit card on file, you will be billed the full session fee at the time of service.
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • January 28th, 2020
Outstanding Bills: It is not our policy to carry balances with our clients. Co-Pays are due at the time of service. Unless there is a financial hardship approved by The Arlington Center, we will charge unpaid co-pays and/or charge deducti-
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • May 2nd, 2022
Credit Card on File AgreementCredit Card on File Agreement • January 19th, 2015
Credit Card on File AgreementCredit Card on 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 AgreementCredit Card on File Agreement • September 20th, 2022
As a Client of Agile Occupational Medicine (“Agile”) and authorized user of the credit card provided below, agree that Agile can securely maintain our credit card information on file with our merchant services. This information will be securely held and will be used under the following conditions:
Credit Card on File AgreementCredit Card on File Agreement • November 20th, 2024
At check in, your credit card information will be obtained and kept securely until your insurance(s) have paid their portion and notifies us of the balance due, if any. At that time, we will charge your credit card for any balance due after insurance has processed your claim(s) in accordance with our contractual obligation with them. Details of the charges can be provided upon request.
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • August 23rd, 2022
Meridian Mental Health & TMS Center of Omaha has implemented a new credit card policy effective 10/01/2022. Anyone that is not responsible for their own financial obligations at this clinic (i.e., if your copay is paid by a parent or spouse), we kindly request for a credit card to keep on file. We are committed to making our billing process as simple and easy as possible and this card will only be used for copays, as they are due at time of service. We will not charge any outstanding balances without your approval. This will help speed up our check in process and be a convenience, so you no longer need to worry about forgetting a form of payment. If you wish to change the credit card on file or have updated card information, please notify our office.
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • May 21st, 2020
By providing us with your credit card information, you are giving Palm Beach Speech-Language Specialists permission to automatically charge your credit card on a weekly, monthly, or as needed basis for the amounts due for services received.
CREDIT CARD ON FILE AGREEMENTCredit Card on File Agreement • June 12th, 2022
Wonder Years Pediatrics now offers the ability for families in our practice to securely store a Credit Card On File (CCOF) which will simplify billing and be used to pay outstanding balances. Once an insurance company has processed and paid
Credit Card on File AgreementCredit Card on 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 AgreementCredit Card on File Agreement • September 9th, 2021
We have implemented a policy which enables you to maintain your credit card information securely on file with Richmond Creative Counseling (RCC). In providing us with your credit card information, you are giving RCC permission to automatically charge your credit card on file for your (or any other patient(s) you have listed on this form) co-pays/co-insurance, outstanding balances, services, and/or products.
Credit Card on File AgreementCredit Card on 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 AgreementCredit Card on File Agreement • January 17th, 2011
As an authorized signer on the credit card listed below, I give Psychological Counseling Services, Ltd. permission to utilize the credit card for all charges related to and including services rendered at PCS.
CREDIT CARD ON FILE (CCOF) AGREEMENTCredit Card on File Agreement • September 24th, 2019
At WeeCare For Kids, we require a credit card on file. This is a convenient method of payment for the portion that your insurance doesn't cover, and for which you are liable. Statements will no longer be mailed to your family.
Credit Card On File AgreementCredit Card on File Agreement • June 18th, 2020
We have implemented a policy which enables you to maintain your credit card information securely on file with Northwest Counseling, Inc. In providing us with your credit card information, you are giving NCI permission to automatically charge this card for any outstanding balance due for you or your dependents.
Credit Card on File AgreementCredit Card on File Agreement • January 28th, 2022
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.
South Hills Integrated Psychiatric Services, P.C.Credit Card on File Agreement • January 30th, 2015
This agreement is required- if you chose to decline this authorization or do not maintain a valid and current credit card on file, billing and unpaid balance fees, and further actions will be implemented as outlined in the practice Financial Policy.
Credit Card on File AgreementCredit Card on File Agreement • March 4th, 2020
I, , authorize Great River Chiropractic Clinic to keep a credit card on file to satisfy my financial obligations as defined by Great River Chiropractic Patient Financial Agreement. I understand that my information is stored safely and securely in a HIPAA compliant manner. I understand that Great River Chiropractic will automatically contact me at least 24 hours prior to using this credit card on file if my balance exceeds $150.
CREDIT CARD ON FILE AGREEMENT:Credit Card on File Agreement • July 15th, 2019
The Brookline Center requires that all clients pay associated visit costs for which they are responsible at the time of service. This includes co-pays, deductibles, co-insurance, no-show, and late cancellation fees.
Moshman Dental Credit Card on File AgreementCredit Card on File Agreement • June 10th, 2020
We have implemented a new, convenient payment policy using a credit card on file, to streamline our billing and payment system and to provide a seamless, convenient way for patients to pay their bills. This is being done in light of the Covid-19 pandemic in order to minimize your time spent in office and maximize infection control.
ContractCredit Card on-File Agreement • September 5th, 2019
FOR REFERENCE ONLY, to apply please use the applicable application link on IMSACompetitors.com or contact registration@imsa.com
