CC Contract Form

Please correct the errors described below.

To Our Patients:

As you know, if you have ever checked into a hotel or rented a car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage for both you and the hotel or rental company, since it makes checkout easier, faster, and more efficient.

We have implemented a similar policy. You will be asked for a credit card number at the time you check in and the information will be held in your password protected file until your insurances have paid their portion and notified us of the amount of your share. At the time, any remaining balance owed by you will be charged to your credit card, and a copy of the charge will be either mailed or emailed to you.

This will be an advantage to you, since you will no longer have to mail us checks or call in to make payment over the phone. lt will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. The combination will benefit everybody in helping to keep the cost of health care down.

This in no way will compromise your ability to dispute a charge or question your insurance company's determination of payment.

Copays due at the time of the visit will, of course, still be due at the time of the visit.

lf you have any questions about this payment method, please do not hesitate to ask.

Sincerely yours,

I authorize James R. Bond, Jr., M.D., P.A. to charge outstanding balances on my account to the following credit card. This will be kept on file and updated yearly.

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