WCP - Payment Authorization Form

WCP - Payment Authorization Form

As a cost and time saving measure for our patients, providers and staff, we have implemented a convenient way for you to settle any balance due on your account.

By completing and signing this form, you are authorizing Whole Child Pediatrics to use your credit card for the charges your insurance carrier has determined to be your responsibility. You will receive a statement from Whole Child Pediatrics informing you of your balance. If you have not paid your statement balance in full by the due date of the 15th, you authorize Whole Child Pediatrics to charge your credit card. You will continue to receive an Explanation of Benefits (EOB) from your insurance carrier detailing your insurance carrier’s payment (if any), negotiated adjustments and any balance determined to be your responsibility.

The advantage is you will no longer have to mail us your payment, pay through our website and eliminates late fees. It is also an advantage to us since it will greatly decrease the number of statements needing to be generated and mailed. The combinations will benefit everyone in helping to reduce the cost of healthcare.

IMPORTANT: this will in no way compromise your ability to dispute a charge or question your insurance carrier’s determination of payment. Co-pays remain due at the time of your visit as will payment in full for all ministry sharing (self-pay) patients.

The following information and my signature shall serve as my authorization for Whole Child Pediatrics to charge my credit card for my family’s accounts. I may cancel this authorization at any time by providing Whole Child Pediatrics with a written request to cancel the authorization. I am also aware if the primary card is a Flexible Spending Account card (FSA) or Health Reimbursement Account card (HRA) I am required to leave an additional card on file, to be used, in the event the charges decline on the primary card.