It may become necessary to release your protected health information to financial parties, credit card entities, banks, and financing companies when requested to facilitate your payment.

Services that are performed and are paid with a credit card, debit card or financing third party are not eligible for payment challenges after services are provided. By signing this form, I am irrevocably consenting to allow Dr. Gallegos to use and disclose my protected health information to any credit card entity, bank, or financing company when requested to such information to process an account and assist with payment.

(initial) I will not challenge such credit, debit, bank or financing card payments once the services have been provided. The practice encourages complete post-op care and follow-up interaction to address any issues that might arise, which are further addressed in the Revision Policy.
(initial)   I agree that his noncredit card challenge agreement is irrevocable.