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, 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.

You are also aware at check-in, At check-in, your credit card information will be obtained and kept securely until your insurance has paid its portion and notifies us of the balance due, if any. You will then be sent a statement which you will have until the due date to review and pay your balance. If the balance remains unpaid, we will bill your credit card. Copays are always due at the time of

The advantage is you will no longer have to worry about your account going into a suspended status and not being able to schedule appointments or having appointments postponed. It is also an advantage to us since it will greatly decrease the number of statements needing to be generated. 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 well as payment in full for all 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.

You are aware that Whole Child Pediatrics will no longer mail out billing statements and they will be sent directly to the patient portal. You are also aware you are responsible for completing a patient portal consent form to activate the patient portal. If you are a self-pay patient you agree that if you leave the office and have not paid for all services rendered for that visit we will use the payment method on file to satisfy what is owed and we will not send you a statement for the balance on the account.

If you or your family's account is placed into a suspended status you we be required to pay the current balance that is on the account (this may include charges you have not yet received a statement on), in full, in order to be able to schedule any appointments. Once in this status, we will only accept payment by utilizing the payment method provided to us on this form, we are unable to take payment over the phone once in a suspended status.

You also agree to authorize Whole Child Pediatrics to use any card(s) provided at check-in as a payment method for said account and are aware it/they will be securely stored in the system. You also authorize Whole Child Pediatrics to process said card(s), even though not processing in person, with the same authorization as the original card(s) provided on the payment method on file form.