We have implemented a policy which enables you to maintain your credit card information securely on file with CARMAhealth. In providing us with your credit card information, you are giving CARMAhealth permission to automatically charge your credit card on file for your co-pay at 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.
Co-pays: Co-pays are due at time of the office visit. You will receive email confirmation of the transaction.
Outstanding Balance: If your insurance provider has paid their portion of your bill and there is an outstanding balance owed, CARMAhealth is authorized to charge my credit card as payment for any balance put into the “patient responsibility” as a result of my insurance plan’s deductible, co-insurance or co-payment. I understand and agree that this payment will be processed five(5) days after the claim is finalized and when we receive a copy of the Explanation of Benefits (EOB) from my insurance plan. CARMAhealth will also provide me with a receipt as proof of payment via email. This in no way compromises your ability to dispute a charge or question your insurance company’s determination of payment.
Expiration/Declined/Card change: If the credit card that I give today changes, expires, or is denied for any reason, I agree to immediately give CARMAhealth a new, valid credit card which I will allow them to charge over the telephone. Even though CARMAhealth is not processing the new card in person, I agree that the new card may be used with the same authorization as the original card I presented.