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.