Patient Information Regarding Credit Card on File Policy

Patient Information Regarding Credit Card on File Policy
We have implemented a policy requiring a credit card held on file. As you may be aware, the current healthcare market has resulted in insurance policies increasingly transferring costs to you, the insured. Some insurance plans require deductibles and copayments in amounts not known to you or us at the time of your visit.

Similar to hotels and car rental agencies, you are asked for a credit card number at the time you check-in, and the information will be held securely until your insurance(s) have paid their portion and notified us of the amount of your share, then you will receive a statement. This card can be charged for the following reasons:
- Visit payments not collected from you at the beginning of your visit
- No-show or late cancellation charges
- Insurance discrepancies that are not resolved within 90 days of the date of service
- Outstanding balance greater than 90 days past due
This is an advantage since it makes checkout easier, faster, and more efficient. This in no way will compromise your ability to dispute a charge or question your insurance company's determination of payment.
Client's Name*

First NameLast Name
Cardholder's Name*
Email
example@example.com
Phone Number
Please enter a valid phone number.
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing this form, I am authorizing Center for New Pathways to charge my credit card for copays 24 hours prior to the session, and any balances that are left after insurance payments.
Signature*

Powered by Jotform SignClear
Printed Name:*
Relationship to Patient:
Date:*

MonthDayYear
Date
Should be Empty: