How your card number is collected
For your security, full card numbers and CVV codes are never typed into or stored on this website. After you submit this authorization, our Patient Experience team will send you a secure payment link to add your card, or collect it by phone.
This page records only your authorization and the policy you agreed to.
Financial policy
We request that a payment card be kept on file for any copayment, co-insurance, deductible, or charge that insurance may not cover. This form is kept confidential; only authorized staff can access it.
1) You agree to receive billing statements, invoices, and receipts via email and through your client portal account. You understand that you must maintain a current email address on file. You will not receive a hard copy of any statement, invoice, or receipt via US mail.
2) Some immediate payment may be expected at the time of service. This will occur if we determine that (i) your insurance plan will not reimburse the cost of your care because the annual deductible is not yet satisfied and/or (ii) your plan includes a cost share, such as a copayment or coinsurance.
3) You authorize us to apply charges to your payment card for all amounts owed for visits, procedures, or supplies at the close of your appointment. This includes (i) any amounts agreed upon as part of a payment plan, (ii) copayments, (iii) coinsurance after application of insurance proceeds, (iv) services not covered by insurance, and/or (v) fees charged for failure to keep a scheduled appointment or provide timely notice of cancellation as per our Cancellation Policy.
4) Once a payment is processed, you understand it may take 3 to 5 business days before the charge is settled with your bank.
5) You acknowledge that your payment card will be charged for any outstanding balance if payment is not received within thirty days of receiving care or an electronic billing statement.
6) You agree to update any information regarding this payment card account should it expire or change.