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
service.

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.

WCP - Payment Authorization Form

WCP
Version: 6
Created: 07/27/2023
Family/Patient Last Name

If your family has more than one last name please list all last names so we can use this authorization for all family members.
IF THERE ARE ANY FAMILY MEMBERS WHO YOU DO NOT GIVE US AUTHORIZATION TO USE THIS CARD ON PLEASE LIST THEIR FIRST AND LAST NAME BELOW:
Email
Phone Phone - ### - ### ####
Family Billing Address Family Billing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please Enter Your Card Information
Is this a Health Savings Account, Flexible Spending Account or Health Reimbursement Arrangement Card?

Is this a Health Savings Account, Flexible Spending Account or Health Reimbursement Arrangement Card? Yes No

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.
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?

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? Yes No
Type of Card
Cardholder Name

SIGNATURE ON FORM BELOW MUST MATCH THIS NAME
Card Number
Maximum of 16 characters allowed. Currently Entered: 0 characters.
Expiration Date Expiration Date / MM / DD YYYY
CVV (3 or 4 digit number on card)
Must be between 3 and 4 digits. Currently Entered: 0 digits.
Billing Zip Code
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 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. I 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.

I agree I will not dispute the charges with my credit/debit card company. I agree I will not ask for a reversal of charges for no cardholder authorization, good faith collection, or any other reason as I agree services were rendered or I violated one the of the policies and I am responsible for 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.
CLICK TYPE AND TYPE YOUR NAME.

SIGNATURE MUST MATCH THE NAME OF THE CARDHOLDER.

Draw or Type

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

Full Name

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.
Secondary card on file
Secondary Cardholder Name

SIGNATURE ON FORM BELOW MUST MATCH THIS NAME
Secondary Type of Card
Secondary Card Number
Maximum of 16 characters allowed. Currently Entered: 0 characters.
Secondary Expiration Date Secondary Expiration Date / MM / DD YYYY
Secondary CVV (3 or 4 digit number on card)
Must be between 3 and 4 digits. Currently Entered: 0 digits.
Billing Zip Code
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 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. I 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.

I 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. I 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.

I agree I will not dispute the charges with my credit/debit card company. I agree I will not ask for a reversal of charges for no cardholder authorization, good faith collection, or any other reason as I agree services were rendered or I violated one the of the policies and I am responsible for 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.
CLICK ON TYPE and TYPE YOUR NAME.

SIGNATURE MUST MATCH THE NAME OF THE SECONDARY CARDHOLDER.

Draw or Type

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

Full Name

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.
Back up card if primary is FSA, HSA or HRA card.
BACKUP Type of Card
BACKUP Cardholder Name

SIGNATURE ON FORM BELOW MUST MATCH THIS NAME
BACKUP Card Number
Maximum of 16 characters allowed. Currently Entered: 0 characters.
BACKUP Expiration Date BACKUP Expiration Date / MM / DD YYYY
BACKUP CVV (3 or 4 digit number on card)
Must be between 3 and 4 digits. Currently Entered: 0 digits.
Billing Zip Code
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.

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 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. I 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.

I agree I will not dispute the charges with my credit/debit card company. I agree I will not ask for a reversal of charges for no cardholder authorization, good faith collection, or any other reason as I agree services were rendered or I violated one the of the policies and I am responsible for 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.
CLICK TYPE AND TYPE YOUR NAME.

SIGNATURE MUST MATCH THE NAME OF THE CARDHOLDER.

Draw or Type

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

Full Name

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.
Date of Signature

I state that the signature(s)/mark(s) are 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. Date of Signature

I state that the signature(s)/mark(s) are 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. / MM / DD YYYY

WCP - Payment Authorization Form

WCP - Payment Authorization Form

WCP - Payment Authorization Form

Please Enter Your Card Information

Please Sign

Secondary card on file

Please Sign

Back up card if primary is FSA, HSA or HRA card.

Backup Signature