KAE Cubs Pediatrics Cardholder Form

KAE Cubs Pediatrics Cardholder Form

Authorize KAE Cubs Pediatrics to securely bill your account for outstanding balances. Please complete all required fields.
To streamline billing and reduce interruptions in care, KAE Cubs Pediatrics requires a valid credit or debit card to be securely stored on file for patient financial responsibilities, including copayments, deductibles, coinsurance, self-pay charges, missed appointment fees, and non-covered services.
1. Authorization Terms
  • Secure Storage: Your card is stored via a PCI-compliant, encrypted system. We can only see the last four digits—not the full card number.
  • When Your Card May Be Charged: For balances unpaid at the time of service, including:
2. Copays/deductibles
  o Denied or non-covered charges
  o Late cancel/no-show fees
  o Self-pay or concierge visits
3. Notifications: You will receive an email or paper receipt for every charge. For amounts over $100, we will notify you before processing.
4. Disputes & Changes: You may cancel this authorization in writing at any time. You are responsible for keeping card details current.
5. Non-Payment Policy: While providing card info is voluntary, any account that becomes delinquent may be required to place a card on file to remain in the practice. Once your card information is securely entered into our HIPAA-compliant EMR system, this form will be immediately shredded and properly disposed of.
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Cardholder Name

First NameLast Name
Billing Zip Code
Card Expiration Date (MM/YY)
CVC (3 or 4 digits)
Full Card Number:
Signature of Parent/Guardian
Signature Date

MonthDayYear
Date
Should be Empty: