WCP Credit Card On File Form 2025

WCP Credit Card on File Form
At West Cary Psychiatry we give you the option of keeping your credit or debit card on file as a convenient method of payment for the portion of services that your insurance doesn’t cover, but for which you are liable. Uncovered fees include, but are not limited to, late cancellation fees, no-show fees, urgent after-hours refill requests, form completion, and letters.

Please review our office Policies and Procedures on our website for more detailed information regarding fees that may not be covered by your insurance. Your credit/debit card information is kept confidential and secure. Co-pay fees are charged to your card after you have attended your appointment, for in-office visits and the prior business day for virtual appointments.

Non-covered fees are charged to your card as they occur. All other fees are charged to your card only after the claim has been filed and processed by your insurance company, and the insurance portion of the claim has been paid and posted to the account.
Cardholder Authorization

I authorize West Cary Psychiatry to charge the portion of my bill that is my financial responsibility to the following credit or debit card:
First 4 Numbers*
Second 4 Numbers*
Third 4 Numbers*
Final 4 Numbers
Expiration Date (MM/YY)*
CVI*
Cardholder Name*

First NameLast Name
Billing Address for Credit Card*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cardholder Signature*

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Patient Authorization
I, the undersigned, authorize and request West Cary Psychiatry to charge the above credit card, indicated above, for balances due for services rendered that my insurance company identifies as my financial responsibility.

This authorization relates to all balances due for uncovered fees which are not covered by my insurance company for services provided to me by West Cary Psychiatry.

This authorization will remain in effect until I (we) cancel this authorization. To cancel, I (we) must give a 60 day notification to West Cary Psychiatry in writing and the account must be in good standing.
Please call before charging any amount over: $
Patient Name*

First NameLast Name
Patient Signature*

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Date*

MonthDayYear
***there is a 3.68% credit card convenience fee

***any balance over 60 days not on a payment plan will be charged in full on day 61.
Should be Empty:

WCP Credit Card on File Form

Cardholder Authorization

Patient Authorization