CC Authorization Form

Credit Card on File Billing Authorization Form

Heart and Health Medical is offering a secure and convenient method of payment for the portion of services that your insurance does not cover, but for which you are responsible. This would include co-payments, co-insurance, and annual deductibles. Your credit card information will be kept confidential and secure, and payments to your card are processed only after the claim has been filed and processed by your insurance carrier.

* Our updated policy for insurance plans with in-office deductibles of $500.00 and up, requires a credit card/HSA card to remain on file.

I authorize Heart and Health Medical to capture my credit card information and 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 after the claim is finalized and when we receive a copy of the Explanation of Benefits (EOB) from my insurance plan. Heart and Health Medical will also provide me with a receipt as proof of payment.

I understand and agree that this form is valid until I give a 30-day written notice to cancel the authorization to Heart and Health Medical, PLLC, Attn: Billing Dept., 6175 Sunrise Highway, Massapequa, NY 11758.

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

Patient Name

Card Holder's Name (as shown on card)

Card Type

VisaMaster CardDiscoverAmerican Express

Expiration date (mm/yy)

Date

Credit Card Number

CVV Code

Address

Email Address

Street Address Line 2

Billing Zip Code

Date

Cardholder Signature

Credit Card on File Billing Authorization FAQ

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.

A: Yes, we keep your credit card info securely within your HIPAA compliant Electronic Medical Record and Billing System in addition to an encrypted payment gateway.

Q: What if I need to discuss 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 as part of patient responsibility on your EOB. The Billing Department can be reached at 516-804-2100. If you disagree with how your insurance carrier processed the claim you will need to contact their customer service department directly.

HEART AND HEALTH MEDICAL, PLLC