This is a contract agreeing to pay for services once patient liability has been determined.
Maximum Charge Amount in 365 days; $3,000.00
By agreeing to store your card, if you have any future charges, our office will only charge your card up to $300 per visit and no more than $3,000.00 per 365 days. Your card will remain on file for 365 days, and will only be charged for your part of the bill.
I agree to allow the practice to charge my credit card for the balance due, as determined by the final adjudication of this and all other claims included under this contract. I agree to the final adjudication amount as defined by my insurance company, with exceptions as noted below.
I agree to these charges under the following conditions:
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