Pediatric Specialists of Tulsa (PSOT) requires a credit card to be on file. Our credit Card transaction company is Instamed. Instamed stores the information on a separate, secure site. This enables us to run credit card transactions within our system. Office personnel will not have access to your card. Only the last 4 digits of your card will show in our system. Instamed is certified as a Level One Service Provider with the Payment Card Industry (PCI), Data Security Standard, as well as the VISA Cardholder Information Security Program (CISP). They are audited and scanned for PCI compliance and is regularly scanned for vulnerabilities by ScanAlerT and is a member of their HACKER SAFE program.
Credit Cards on fie will be used for:
Copays- When you come into the office, we will ask you if you want to use the credit card on file. You may choose to present another card if preferred or any other form of payment accepted by our office.
Deductibles- We require payment at time of service. Your credit card on file will be utilized to settle any additional balances that were not credited to your account at time of service.
Co-Insurance- For your percentage not covered by insurance not paid at time of service. For example: If your insurance covers at 90% we will require the 10% on the day of the appointment.
Balances- If your account has an outstanding balance, we will attempt to call you 3 times, after the 3rd attempt we will utilize the credit card on file.
For all patient responsibility amounts assigned by insurance, our office reviews these amounts to ensure your claim has been properly adjudicated. If what is adjudicated by the insurance company does not match your benefits we verified with insurance at the time of service, we will contact you and your insurance carrier. Members typically receive their explanation of benefits prior to the provider, so if you disagree with the patient responsibility amount owed, it is your responsibility to contact your insurance carrier immediately.
Should your credit card be mistakenly run, we will immediately issue a refund.
During the time you leave a credit card on file, if it expires or otherwise becomes uncollectable, we will expect you to promptly provide a new means of payment.
Credits on your account after your insurance claim has been adjusted will be returned to the credit card on file.
We do our best to verify your benefits prior to the appointment to make sure we collect the appropriate amount owed and to make sure your visit will be covered by your insurance plan. However it remains the policy holder’s responsibility to know their insurance policies. PSOT cannot know all the details of every plan. Ultimately, you are responsible for knowing what services are covered, how often, and how much of the cost is your responsibility. You will be responsible for any portion of services that your insurance does not cover.
Credit Card on File Authorization
I agree to place my credit card on file to be run by Pediatric Specialists of Tulsa. I authorize their staff to run my credit card for purposes stated above.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.