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WCP - Payment Authorization Form
WCP
Version: 5
Created: 09/19/2021
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If your family has more than one last name please list all last names so we can use this authorization for all family members.
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Please Enter Your Card Information
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Is this a Health Savings Account, Flexible Spending Account or Health Reimbursement Arrangement Card? *
PLEASE NOTE, YOU ARE REQUIRED TO PUT A BACKUP CARD ON FILE IF YOUR PRIMARY CARD IS A HEALTH SAVINGS ACCOUNT, FLEXIBLE SPENDING ACCOUNT OR HEALTH REIMBURSEMENT ARRANGEMENT CARD.
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Would you like to keep a secondary card on file as a backup payment method if the primary card is not a Health Savings Account, Flexible Spending Account or Health Reimbursement Arrangement Card? *
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SIGNATURE ON FORM BELOW MUST MATCH THIS NAME
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Maximum of 16 characters allowed. Currently Entered: 0 characters.
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Must be between 3 and 4 digits. Currently Entered: 0 digits.
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Please Sign
*I authorize Whole Child Pediatrics to charge my credit card, for my family’s accounts, if the statement balance has not been paid in full before the due date listed on the bottom of the statement. I am aware I may cancel this authorization at any time by providing Whole Child Pediatrics with a written request to cancel the authorization. I also understand that should my payment decline for any reason, that my family’s accounts will be suspended and all future appointments will be cancelled.
I am aware and agree that if I have a balance that is less than $5.00 I will not receive a statement and Whole Child Pediatrics will charge my card on file for the balance on the account. I am aware I may contact the office and request a copy of the receipt showing the charges. If I am a self-pay patient I agree that if I leave the office and have not paid for all services rendered for that visit Whole Child Pediatrics will use the payment method on file to satisfy what is owed and they will not send me a statement for the balance on the account.
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I understand this is a legal representation of my signature.
The eSIGN act of 2000 established the legal basis for the use of electronic signatures in the United States as an alternative to paper signatures. By completing this form your signature or mark will be legally binding.
Clear
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Secondary card on file
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SIGNATURE ON FORM BELOW MUST MATCH THIS NAME
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Maximum of 16 characters allowed. Currently Entered: 0 characters.
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Must be between 3 and 4 digits. Currently Entered: 0 digits.
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Please Sign
*I authorize Whole Child Pediatrics to charge my credit card, for my family’s accounts, if the statement balance has not been paid in full before the due date listed on the bottom of the statement. I am aware I may cancel this authorization at any time by providing Whole Child Pediatrics with a written request to cancel the authorization. I also understand that should my payment decline for any reason, that my family’s accounts will be suspended and all future appointments will be cancelled.
If my family's account goes into suspended status for any reason, I am aware that is there is a balance on the account (whether a statement has been received or not) this payment method will be used to satisfy said balance to be taken out of suspended status.
I am aware and agree that if I have a balance that is less than $5.00 I will not receive a statement and Whole Child Pediatrics will charge my card on file for the balance on the account. I am aware I may contact the office and request a copy of the receipt showing the charges. If I am a self-pay patient I agree that if I leave the office and have not paid for all services rendered for that visit Whole Child Pediatrics will use the payment method on file to satisfy what is owed and they will not send me a statement for the balance on the account.
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I understand this is a legal representation of my signature.
The eSIGN act of 2000 established the legal basis for the use of electronic signatures in the United States as an alternative to paper signatures. By completing this form your signature or mark will be legally binding.
Clear
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Back up card if primary is FSA, HSA or HRA card.
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SIGNATURE ON FORM BELOW MUST MATCH THIS NAME
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Maximum of 16 characters allowed. Currently Entered: 0 characters.
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Must be between 3 and 4 digits. Currently Entered: 0 digits.
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Backup Signature
*I authorize Whole Child Pediatrics to charge my credit card, for my family’s accounts, if the statement balance has not been paid in full before the due date listed on the bottom of the statement. I am aware I may cancel this authorization at any time by providing Whole Child Pediatrics with a written request to cancel the authorization. I also understand that should my payment decline for any reason, that my family’s accounts will be suspended and all future appointments will be cancelled.
I am aware and agree that if I have a balance that is less than $5.00 I will not receive a statement and Whole Child Pediatrics will charge my card on file for the balance on the account. I am aware I may contact the office and request a copy of the receipt showing the charges. If I am a self-pay patient I agree that if I leave the office and have not paid for all services rendered for that visit Whole Child Pediatrics will use the payment method on file to satisfy what is owed and they will not send me a statement for the balance on the account.
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I understand this is a legal representation of my signature.
The eSIGN act of 2000 established the legal basis for the use of electronic signatures in the United States as an alternative to paper signatures. By completing this form your signature or mark will be legally binding.
Clear
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