2.) If you, as the patient, miss a scheduled appointment without 24 hour notice to cancel or reschedule, CFFAC reserves the right to charge the credit card listed below, $35.00 for our standard no-show fee. This notice serves as your consent to be charged for all no-shows. A receipt will be mailed upon your request. (As is customary, an automated system for CFFAC will call the phone number on file to remind you of your scheduled appointment. this reminder is usually done 24 hours prior to your scheduled appointment. It is the patient's responsibility to ensure that we have a correct, current telephone number on file)
3.) If you, as the patient, request paper records and do not pick the records up after preparation, CFFAC reserves the right to charge the credit card on file for the fees involved. (Medical Record Policy will be followed: consent must be signed, pt will be notified of the cost prior to preparation, CFFAC will release within 5 business days or receipt of request, pt will be notified once ready)
Other than the conditions mentioned above, under NO circumstance will CFFAC charge your credit card for anything not discussed with you personally. In conjunction with HIPAA regulations, all credit card information will be confidentially kept within your medical chart in our office. Only authorized staff will be able to access this information.
Acknowledged, Agreed, and Accepted:
Having read this form and talked with the physician, and/or staff, my signature below acknowledges that I voluntarily give my authorization and consent to providing the requested information for my credit card to be charged accordingly for the conditions listed above.
*** Please note: If you are paying by CASH, Flex Spending Card or HSA Visa/Mcard today for your copay, deductible, coinsurance, noncovered services, supplies, etc., you will still be required to place a credit card on file that is saved to the bank’s secure database or complete info below. Please be prepared to provide this information to the front desk at check-in prior to being seen***