Patient Credit Card on File Agreement

Patient Credit Card on File Agreement

Version: 2025
Would you like to keep a credit card on file at the Boston Ability Center for your child's services?*

Yes, I would like to put a credit card on fileNo, I would NOT like to keep a card on file
- We ask that you provide your credit card information for secure storage in our system.
- At the time of service, your credit card will be processed for balance due at the time of service. This may include co-pay, co-insurance, self-pay rate, or outstanding balance. If a caregiver or nanny will be bringing your child to the appointments, a credit card must be saved on file to facilitate this process.
- After receiving remittance from your insurance company, a patient responsibility balance may remain. In this situation, your credit card on file will be processed for the balance due and a receipt will be sent to the email we have on file.
- By signing this form you authorize this agreement will remain in effect until the expiration of the credit card account, or until we receive your request to remove the credit card information on file.
- If you have a question regarding this policy or an email receipt you have received, please contact billing@bostonabilitycenter.com
- Multiple Users: This card will only be authorized for the use of the credit card holder, his/her minor(s), or any person(s) listed below.
I authorize The Boston Ability Center, to charge co-pays and account balances on my account to the following credit card:
Type of Credit Card*

VisaMasterCardAmerican ExpressDiscover
Is this a HSA or FSA card?*

Yes, HSAYes, FSANo
Credit Card Holder's Name*

First NameLast Name
Last 4 digits of credit card number*
I authorize that this credit card be stored on file for each patient listed below (Please include full name(s) for each child who you would like this credit card saved for). *
Signature of Parent or Legal Guardian*

Clear
Print Name of Legal Guardian*
Date*

MonthDayYear
Date
I do not wish to put a credit card on file. I understand that payment is due at the time of service and that it is my responsibility to pay for each session by checking in at the front desk window and providing a check or credit card at the beginning of my child’s appointment.
Patient's name

First NameLast Name
Signature of Parent or Legal Guardian*

Clear
Print Name of Legal Guardian*
Date*

MonthDayYear
Date
Should be Empty: