WF - 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 Family Integrative Health to use your credit card for the charges your insurance carrier has determined to be your responsibility. You will receive a statement from Whole Family Integrative Health informing you of your balance. If you have not paid your statement balance in full by the due date, you authorize Whole Family Integrative Health 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.

I also agree to authorize Whole Family Integrative Health 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 Family Integrative Health 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.

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 Family Integrative Health to charge my credit card for my family’s accounts. I may cancel this authorization at any time by providing Whole Family Integrative Health 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.

WF - Payment Authorization Form

WF
Version: 5
Created: 09/19/2021
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.
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 Family Integrative Health 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 Family Integrative Health 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 also agree to authorize Whole Family Integrative Health 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 Family Integrative Health 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.
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 Family Integrative Health 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 Family Integrative Health 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 also agree to authorize Whole Family Integrative Health 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 Family Integrative Health 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.
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 Family Integrative Health 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 Family Integrative Health 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 also agree to authorize Whole Family Integrative Health 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 Family Integrative Health 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.
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

WF - Payment Authorization Form

WF - Payment Authorization Form

WF - 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