Credit Card on File Billing Authorization Form

Center for Regenerative & Interventional Spine and Sports Pain (CRISSP) is offering a secure and convenient method of payment for the portion of services that your insurance doesn't cover, but for which you are liable. Your credit card information is kept confidential and secure and payments to your card are processed only after the claim has been filed to and processed by your insurance carrier, and the insurance portion of the claim has posted to your account, or in the event that valid insurance information was not provided at the time of service.

Q: How does the automatic billing process work?
A: Your credit card will be captured today and stored securely. After your insurance carrier responds and
provides us your remaining balance due we may charge the patient responsibility to your credit card on file, not to exceed the maximum balance due indicated in the agreement. Your credit card on file will only be charged when you have a balance owing on your account or for a non-covered service.

Q: How will I know how much you are going to charge me?
A: You will receive an explanation of benefit from your insurance carrier that explains exactly, according to your health insurance coverage and benefits, how much of your healthcare bill is your responsibility and how much the insurance paid along with any contractual adjustments.

Q: What if I need to dispute my bill?
A: We will always work with you to resolve any issues and will refund you if we have made a billing error. We will only charge the amount that we are instructed by your insurance carrier to collect from you in the same way that we normally determine how much to send you a statement for in the mail. If you disagree with how your insurance carrier processed the claim you will need to contact their customer service department directly.

Q: Will I receive a statement or receipt for the charges automatically billed to my card?
A: Not automatically. Your insurance carrier EOB and your credit card statement will be your receipt. You can at any time contact us to have an account itemization emailed to you.

Q: What is a deductible?
A: An annual deductible is the dollar amount you must pay out of your own pocketing during your plan year for medical expenses before your insurance begins to pay. For example, if the policy has a $1,000 deductible, you must pay the first $1,000 of medical expenses before your insurance will begin to pay. Your insurance company must receive a claim to process in order to apply balances towards your deductible. Even if you have a high deductible plan we encourage you to have us submit the claim to your insurance so you receive a contractual adjustment and the services can be applied towards your deductible.

Q: Is my credit card secure?
A: Yes, we do not store your sensitive credit card information in our office. Keeping your card on file, offsite, in an encrypted payment gateway actual enhances security because it reduces exposure at each visit.

I agree CRISSP may charge my credit card on file for the balance due when they receive a copy of the EOB. This authorization relates to all balances not covered by my insurance company for services provided by CRISSP. This could be amounts resulting from balances related to copayment, deductible, co-insurance, non-covered services, or denials for no coverage/eligibility but is not limited to these scenarios.

I understand that this form is valid until I give a 30-day written notice to cancel the authorization to CRISSP. Written notice must be submitted to Center for Regenerative & Interventional Spine and Sports Pain (CRISSP), 4455 Duncan Ave, Suite 8N, St. Louis, MO 63110-1111.

I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.