Please review and complete the policy form below, then attach the finished document in the submission section. Credit Card on File Authorization and Consent Patient Name:(Required)Date of Birth:(Required) MM slash DD slash YYYY MRN (if applicable):(Required)Date:(Required) MM slash DD slash YYYY Purpose I authorize [Practice/Clinic Name] (“Practice”) to store my payment card information in a secure, encrypted payment vault (“safe vault”) maintained by the Practice and/or its designated payment processor, and to use that payment method for charges as described below.What I Am Authorizing By signing this form, I authorize the Practice to charge my card on file for any of the following, as applicable: Copayments, coinsurance, and deductible amounts Outstanding balances after insurance adjudication (including patient responsibility) Non-covered services, self-pay services, and other patient-pay amounts I have agreed to No-show/late cancellation fees, if applicable per Practice policy Payment plan installments, if applicable and agreed upon How My Card Information Is Stored My card information will be stored in a secure payment vault (“safe vault”) and not written on paper or stored in an unencrypted format within the office. For security, the Practice may store a tokenized reference to my card rather than the full card number. The Practice will follow applicable privacy and security standards to help protect my information; however, no system can be guaranteed to be 100% risk-free. Receipts and Notifications I may request a receipt for any transaction (paper and/or electronic, where available). If the Practice sends electronic notices (text/email), standard messaging rates may apply. My Choices and Rights I may revoke this authorization at any time by submitting a written request to the Practice. Revocation will not affect charges already incurred or services already provided. I agree to notify the Practice promptly if my card changes, expires, or is replaced. Patient Acknowledgment I have read and understand this authorization. I agree that I am financially responsible for applicable patient-pay amounts and authorize the Practice to store my card in a secure vault and charge it as described.Cardholder Name (print):(Required)Relationship to Patient (if not self):(Required)Signature(Required)Date MM slash DD slash YYYY Phone:(Required)Email:
