Credit Card Consent Form


Patient First Name*:
Patient Last Name*:
Patient Date of Birth*: (mm/dd/yyyy)
Date of Request*: 10/14/2019

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:

  • The charges will take place upon receipt, or within a few days, of the final explanation of benefits from my insurance company.
  • The amount charged to my card will not exceed the agreed-upon maximum dollar amount.
  • I will receive a bill from the practice for any balance greater than maximum dollar for which I am liable.
  • This contract is valid for one year starting from today.
  • My credit card will be stored by a secure credit card processor affiliated with U.S. Bank that partners with the practice to collect payments.
  • I will receive a receipt for any amount charged to my card once the transaction is complete.
  • I may cancel this agreement at any time by contacting the practice.
Guardian/Patient*:    Date*: (mm/dd/yyyy)
City*:   State*:   Zip Code*:
Verification Code*: security code
Enter Security Code*: