Credit Card Consent

Bay Area Clinical Associates offers a Credit Card on File program as a convenient method of paying for the portion of your services that are patient responsibility such as copay, deductible, and co-insurance. Your credit card information will be kept confidential and secure.

I, the undersigned, authorize and request that Bay Area Clinical Associates charge my credit card for the balance due that my health plan, if applicable, has identified as my financial responsibility. This authorization relates to all charges not covered by my insurance company for services provided to me by the providers at Bay Area Clinical Associates. My card information will remain securely stored for future use by Coastal Card Systems, a secure credit card processor that partners with Bay Area Clinical Associates to collect payments. This authorization will remain in effect until revoked by me in writing.

By signing below, I authorize Bay Area Clinical Associates to keep my signature and my credit card information securely on-file in my account. I authorize Bay Area Clinical Associates to charge my credit card for any outstanding balances when due:

Card Type:*

VisaMastercardDiscoverAmerican Express

Name on Card*

Card Number*

Expiration Date*

Security Code*

Cardholder relationship to patient

Please fill out information below for any person(s) you authorize this credit card for:

Name of Patient*

First NameLast Name

Patient Date of Birth*

MonthDayYear

Signature* Signature

Date*

MonthDayYear

Email*

*in which to send a form completion receipt