CardPointe Credit Card on File Policy

Edmond Pediatrics now offers the ability for families in our practice to securely store a Credit Card on File (CCOF) which will simplify billing and be used to pay outstanding balances as outlined in this policy. After an insurance company processes and pays their portion of a claim, there is often a patient (parent/guarantor) responsiblity for a balance due to:

Deductible not yet being met
Co-pay or Co-insurance being applied to charges
Insurance company deeming a service is not a covered benefit
Insurance policy not being in effect on the date of service
Newborn or dependent child not added to the policy

After the insurance company processes the claim and issues an Explanation of Benefits (EOB), a billing statement will be sent by Edmond Pediatrics to the guarantor of the account. Any outstanding balance remaining approximately THIRTY DAYS after insurance is processed will be automatically charged to the CCOF. Edmond Pediatrics typically processes CCOF on or close to the second and fourth Tuesdays of the each month. If you have any questions regarding the balance shown on your EOB please call our billing department. Prior to the card being charged, payment may be made by postal mail, phone or online at www.edmondpediatrics.com. For your convenience, the CCOF can be used to pay for co-pays and missed appointment fees.

For families that do not comply with our Credit Card on File Policy, their accounts will be subject to our Re-Billing Policy, effective March 2024 when a balance is greater than 60 days from insurance processing, your account will be charged a $30.00 Re-Bill Fee for every monthly billing cycle that carries a balance.

This agreement does not restrict your right to appeal any charges made to your credit card. Should you feel that an error was made with any charge to your card, you may contact our billing office. Please do not hesitate to ask our front office if you have any questions.

Edmond Pediatrics does not have access to the full credit card number upon submission. Credit cards are encrypted and stored by a third party processor.

Cardholder's Name*

First NameLast Name

Patient's Name*

Patient's NamePatient's Last Name

Patient's Date of Birth *

Please provide child's Date of Birth

Edmond Pediatrics Account Number

Card Brand on File*

VISAMasterCardAmerican ExpressDiscover

Signature*

By signing, I authorize Edmond Pediatrics' credit card processor to keep a credit card on file that may be used for future payments. Additionally, I authorize Edmond Pediatrics to charge any unpaid balance on my account in according to the terms in this agreement. If my billing statement changes or my card is canceled or renewed, I will contact Edmond Pediatrics with new information. If my card is declined, I will pay the balance owed on the account through other means. I understand Edmond Pediatrics does not keep a full record of my card number.

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Edmond Pediatrics Please enter 0.01 for verification of account; upon receipt this 0.01 will be returned to the card on file

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$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

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