Valencia Pediatric Associates Credit Card on File Policy

Valencia Pediatric Associates requires that a valid credit/debit card be kept on file for all its patients.
This policy is designed to:

• Help you avoid all billing related fees.
• Streamline the billing process in our office and eliminate the expenses related to handling overdue accounts.
• Focus our time and energy on your children and their medical care.

Your card information is stored electronically and cannot be viewed by our office staff. Your signature will authorize the card to be used to charge for all patient related balances on your account.

How the policy works:

1. At the time of registration or check-in, you will be asked for your credit/debit card information. For those leaving an HRA/HSA credit card a secondary credit card is required.
2. If there is copay due, you can choose to use the card on file or another form of payment accepted by our office. If someone else brings your child in we will charge your card on file.
3. If you have a coinsurance or deductible due, you can choose to use the card on file or another form of payment accepted by our office. We have reimbursement rates on file for many insurance companies and do ask that you pay your portion at the time of service.
4. As before, we will bill your insurance company for all charges related to the visit. If your insurance company applies any additional patient responsibility amounts, we will charge the card on file for this amount.
5. We will also charge the card on file for missed appointment fees, medical record fees, form fees, or other services not covered by insurance.
6. All balances $500.00 or less will be charged automatically to the card on file. You will only be contacted prior to charging the card on file if the balance exceeds $500.00.
7. Once your card is charged we will publish the receipt to the Patient Portal (for those web enabled) or mail you a receipt of payment.

Please remember that this policy does not restrict your right to appeal any charge made to your credit card. Should you feel that we have charged your card in error, you may contact our billing office.

I have reviewed a copy of Valencia Pediatric Associates’ credit card on file policy and authorize them to keep my signature on file and to charge the below listed credit/debit card for balances not paid or covered by my child’s insurance carrier.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Office Use Only: Manual/Swipe