• Credit Card Authorization

    It is our office policy to require credit card information for each patient. This information is part of your confidential medical chart.

    Why do we need this information?

    • Yes, we do participate with your health plan!
    • Yes, we do accept their negotiated fee as payment in full!
    • However, many plans now subtract deductibles, co pays and coinsurance from this negotiated fee.
      We have no way of knowing what these co pays, deductibles and coinsurance are fully, until payment is received from your plan. The information provided will ONLY be used for these charges when we receive the explanation of benefits from the insurance carrier. We are not responsible as to how your insurance plan processes the claims. Please request a copy of this form for your records. If you elect to decline our request for credit card information and we need to bill you, a $25 fee will be charged. We accept Discover, Visa, MasterCard, and American Express.

    FORM MUST BE COMPLETED BY PATIENT

  • If other than patient:
  • YOU WILL BE ASKED TO FILL THIS FORM OUT AGAIN ONCE THE CURRENT CARD ON FILE EXPIRES.