KAP CC Vault Authorization

Please correct the errors described below.

Credit Card Vault Form

Kid Approved Pediatrics is now setup to process payments for in office, rear entry, curbside, and telehealth appointments utilizing a HIPPA compliant/Encrypted form for vaulting.

  • I understand that my cc will be vaulted securely in a HIPPA compliant cc system for current/future appointments..
  • I understand that should my cc on vault be declined in anyway, KAP will require another form of payment. If secondary payment is un-successful by means of contact or not able to process payment, KAP may choose to suspend patient from future appointments till payment or outstanding balances are resolved.
  • I understand this document will become a part the patients’ medical record.
  • I understand that should the need to cancel a well appointment, I need to contact KAP 24hr in advanced or a $50 charge will be applied to my credit card.
  • I understand that should the need to cancel a sick or nurse appointment, I need to contact KAP 24hr in advanced or a $25 charge will be applied to my credit card.
  • I understand should a SAME DAY well appointment is canceled a $50 charge will be applied to my credit card.
  • I understand should a SAME DAY Sick or Nurse appointment is canceled a $25 charge will be applied to my credit card.
  • I may revoke the right to have a cc vaulted by contacting KAP in writing either by mail or email: staff@kidapprovedpediatrics.net.
  • I understand should I resume vaulting service, I might be required to resubmit a new appointment vault consent form.
  • I authorize KAP to charge the cc for a sick, well or nurse visit.
  • I authorize KAP to charge the cc should I occur a fee should any of the above situations occur.

Patient Billing Address

This will be used for contact purposes only
This will be used for contact purposes and receipts only

Credit Card Info

Must be 16 num
Must be 3 #

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents.

This will be used for contact purposes only
    Please upload a file

    Your message will be encrypted and can only be read by Kid Approved Pediatrics.