Credit Card on File Authorization

Patient's Name*

First NameLast Name

Date of Birth*

As of Jan 1, 2025, San Diego Family Dermatology requires all commercially insured patients to keep a credit card on file or pay upfront for services rendered, for which any balance would be reimbursed at the time of insurance payment. Your credit card information is stored securely with the same HIPAA-compliant software that protects your confidential medical information.

If you choose to keep a credit card on file, you will receive a receipt directly from Square credit care processors. If you so choose, you will also receive an Explanation of Benefits from San Diego Family Dermatology through a non-HIPAA compliant email address. (You can opt in to receiving billing emails even if your preferences are to not receive other emails from SDFD.)

As a reminder, you have already agreed to this financial responsibility policy in your intake forms:

We are committed to providing you with the best possible care, and will help you receive your maximum allowable insurance benefits. However, we need your assistance and your understanding of our payment policy. Your insurance contract is between you, your employer and the insurance company. Not all services are covered by all contracts. We participate and accept assignment from most major payers, which means covered charges, will be paid directly to us. As a courtesy to you, we will file a claim with your insurance carrier on your behalf. Any remaining balance will be billed to you once we have received payment from your insurance carrier. If we do not participate in your insurance plan or if you are uninsured, you may still choose to be seen in our practice as a “SELF PAY” patient. You may be eligible for a discounted “SELF PAY” rate that is due at time of service. If there is a lapse in your insurance, you are responsible for having knowledge of this. If you are unsure, check with your insurer before your appointment. If your insurance does not pay for your visit, you will be held responsible. It is your responsibility to know if we are contracted with your insurance company. We do not accept insurances assigned to: Sharp, Scripps, or UCSD. If your account becomes delinquent (past due), we may take the following actions: (1) refer your account to a collection agency, (2) file a lawsuit to recover the amount owed. If your account is referred to a collection agency, you agree to pay a collection fee and interest at an annual rate of 10% on the unpaid balance, beginning 30 days after the date of service. If legal action is required to collect the amount owed, you agree to pay all reasonable attorney's fees and court costs incurred in the collection process, in addition to the outstanding balance, collection fees, and interest.

PLEASE SELECT YOUR PREFERENCE BELOW*

OPTION 1: I authorize San Diego Family Dermatology to charge my credit card for medical care that is not covered by my insurance, including co-pays, deductibles, and co-insurance. I understand my information will be saved to file for future transactions on my account.OPTION 2: I decline to maintain a credit card on file with San Diego Family Dermatology. I opt to pay upfront for services rendered and be reimbursed once payment has been received from my insurance.

IF YOU SELECTED OPTION 1 ABOVE, WOULD YOU LIKE RECEIPTS AND EXPLANATIONS OF BENEFITS EMAILED TO YOU?

NoYes, and email address is noted below.

Email

example@example.com

You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

Signature* Date*

CREDIT CARD ON FILE AUTHORIZATION