Credit Card Consent Form


Patient First Name*:
Patient Last Name*:
Patient Date of Birth*: (mm/dd/yyyy)
Date of Request*: 6/25/2017

For your convenience, we have implemented a policy with enabled you to maintain your credit/debit card ("Card") information on file with us. With your consent, this information will be securely held to cover future charges and additional fees via Phreesia, which is PCI level 1 compliant.

Signing this consent in no way compromises your ability to dispute a charge or question your insurance company's determination of payment. Your insurance company ultimately determines the amount of money you may owe.

I herby authorize Peachtree Park Pediatrics to keep my Card information on file for payment of any and all charges for medical services for which I am financially responsible and that remain unpaid after applying insurance payments and adjustments, if any. Any balances greater than or equal to $300 per child per visit, a courtesy call will be made to the card holder to inform you the payment will be processed that day.

If my Card information changes for any reason, I will notify you. This consent shall remain in effect until terminated by parent/patient via written consent.

Agreed to:

Guardian/Patient*:    Date*: (mm/dd/yyyy)
City*:   State*:   Zip Code*:
Verification Code*: