CCOF Authorization 2025

RTC Pediatrics Credit Card on File Consent Policy
Patient Responsibility

In accordance with our Financial Policy, patient balances are due within 30 days after insurance pays. If your insurance plan is subject to routine deductibles and coinsurance, we require you to keep a credit card on file so we can collect those charges as soon as your insurance carrier designates your financial responsibility for the claim. We will only charge your credit card without prior notice if the claim was adjudicated normally. If your credit card on file expires or otherwise becomes uncollectable, we will expect you to promptly provide a new means of payment.
Please enter the cardholder's name and contact information associated with the card you will swipe at the Front Desk.
Patient # 1's Name:

First NameLast Name
Date of birth

MonthDayYear
Date
Patient # 2's Name:

First NameLast Name
Date of birth

MonthDayYear
Date
Patient # 3's Name:

First NameLast Name
Date of birth

MonthDayYear
Date
Patient # 4's Name:

First NameLast Name
Date of birth

MonthDayYear
Date
Patient # 5's Name:

First NameLast Name
Date of birth

MonthDayYear
Date
Patient # 6's Name:

First NameLast Name
Date of birth

MonthDayYear
Date
RTC Pediatrics Credit Card on File Authorization
Cardholder's Name*

First NameLast Name
Cardholder's Phone*
Please enter a valid phone number.
Relationship to Patient*
Cardholder's Billing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing below, I agree to RTC Pediatrics Credit Card on File policy, and I authorize RTC Pediatrics to keep my signature and valid credit/debit card number securely and confidentially on file.
Name of Parent/Guardian of Patient if 18+ years old:*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

RTC Pediatrics Credit Card on File Consent Policy

RTC Pediatrics Credit Card on File Authorization