Credit Card Authorization Form - English

Ricardo E. Rodriguez, M.D., F.A.C.G. | Maria D. Soliman, PA-C

Please correct the errors described below.

Credit card on File Agreement

Much like many other businesses such as hotel or rental agencies, medical practices, attorneys, etc Continuum Gastroenterology Care has a similar policy where we ask for a credit card which may be used later to pay any balances that may be due on your account.

In Network Patients:

Your credit card information will be obtained and kept securely until your insurance(s) have paid their portion and notifies us of the balance due, if any. Balances owed will be applied to the card on file. These transferred amounts are outlined in the Explanation of Benefits (EOB) that is mailed or emailed to you by your insurance company. Your ability to dispute a charge or question your insurance company’s determination of payment will remain unchanged. If you have any questions about our policy, please read the FAQ on the back and do not hesitate to ask.

Out of Network Patients:

All balances are due at the time of service. The card of file will be charged accordingly the day of your appointments / procedure.

New patient Appointment Deposit:

Our office requires a deposit for holding new patient appointments time slots. This deposit will be applied towards your initial visit. If you are not sure you are going to be able to keep your new patient appointment, please do NOT schedule at this time. Charges for deposit are $100.00 for new patient appointments. If for any reason you don’t show up to your new patient appointment or you don’t cancel within 24 hours your credit card will be automatically charged a non-refundable fee of $100.00.

Follow up / Procedure appointments:

Due to the increased number of missed appointments and or/ canceled appointments / procedures. The office has found it necessary to charge a non-refundable fee of $50 for no-show appointments or late cancellation appointments and a non-refundable fee of $200 for no-show procedure appointments and late cancellations procedure appointments. If you have any questions please refer to our procedure agreement.

By signing below, I authorize Dr. Ricardo E. Rodriguez to keep my signature and my credit card information securely on-file in my account. I authorize the office of Dr. Ricardo E Rodriguez to charge my credit card for any outstanding balances when due.

If the credit card that I give today changes, expires or is denied for any reason, I agree to immediately give the office of Dr. Ricardo E. Rodriguez a new valid credit card which I will allow them to charge over the telephone. Even though the office of Dr. Ricardo E. Rodriguez is not processing the new card in person, I agree that the new credit card used with the same authorization as the original card I presented. I authorize the above name business to charge the credit card indicated in this authorization form according to the terms outlined above. I certify that I am an authorized user of this credit card and that I will not dispute payment with my credit card company; so long as the transaction corresponds to the terms indicated in this authorization form. Should you wish to revoke this authorization at any time please send written notice to the office.

Frequently Asked Questions Regarding the Credit Card on File Agreement

Do I have to leave my credit card information to be a patient at this practice?

Yes. This is our policy and it is a growing trend in the healthcare industry. Insurance reimbursements are declining and there has been a large increase in patient deductibles. The amount of time and effort to collect payments that will be saved will allow our office to focus more on patient care. We have decided to focus on becoming more efficient in our billing and collections processes instead.

How much and when will money be taken from my account?

The insurance companies on average take approximately 2-3 weeks to process submitted claims. Whatever the allowed amount is, your copay, coinsurance, and deductible are taken into consideration. It simply depends on your individual policy what you may owe. Once the insurance explanation of benefits is received and posted to your account, you will be sent a statement showing your portion. You will have 30 days to send an alternative form of payment if you prefer. If no alternative payment is received, your patient's financial responsibility will be processed.

How do you safeguard the credit information you keep on file?

We use the same methods to guard your credit card information as we do for your medical information. The card information is securely protected by the credit card processing component of our PCI and HIPAA compliant practice management system. This system stores the card information for future transactions using the same sort of technology that any online retailer would. We can’t see the card number – only the last four numbers, giving us no way to use the card outside of the billing system. There is no way to export the card information out of our system. The only way to use it is to process a payment in our practice management system.

What are the benefits?

It saves you time and eliminates the need to write checks, buy stamps or worry about delays in the mail. It also drives our administrative costs down because our staff sends out fewer statements and spends less time taking credit card information over the phone or entering it from the billing slips sent in the mail, which are less secure methods than us storing the information. The extra time the staff has can now be spent on directly helping the patients, either over the phone, with insurance claims or in person.

I always pay my bills on time.

Why do I have to do this? The entire billing process is time consuming and wasteful, and the few patients that we do have to send to a collection agency end up costing a lot of money. Reducing unnecessary costs are essential to allowing us to continue to be your provider. Nothing is changing about how much you end up paying.

What if there is a payment discrepancy or I have other payment questions?

Please contact our office directly to settle payment discrepancies or for other payment questions. This policy in no way compromises your ability to dispute a charge or questions your insurance company’s explanation of benefits.

Will I still receive a receipt/invoice bill by mail?

Yes. You will receive a paid receipt/invoice for each transaction by mail or email based on your preference.

Your information will be encrypted.

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