Credit Card Authorization for copay, coinsurance etc..
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I have a template for getting authorization from patients to cover their copay as well as collect the whole contracted rate if they still have a deductible. If they have large deductible, I charge amount close to contracted rate at the time of appointment so I don't need to engage billing service or worry about payment later on. Don't know how to post it here. 

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    Gillian

    Hi Sanjeev, you can post the text of the form in a comment, or upload it to a cloud-based storage and share a link to it if you'd like. Let me know if you'd like any assistance - I'm sure our community would truly appreciate your sharing this resource!

    Hi Sanjeev, you can post the text of the form in a comment, or upload it to a cloud-based storage and share a link to it if you'd like. Let me know if you'd like any assistance - I'm sure our community would truly appreciate your sharing this resource!

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    Sanjeev Singhal MD

    Credit Card Authorization for Payments

    * indicates a required field

    Frederick Psychiatry requires a method of payment for the portion of services APPROVED BY Carefirst Bluecross, but for which you are responsible, such as COPAY and DEDUCTIBLES. Your financial information is kept confidential and secure. A credit card method of payment is preferable.
    1. IF YOU HAVE NOT MET YOUR DEDUCTIBLE, payments to your card are processed on the day of appointment as specified below.
    2. If you have met your deductible, only your COPAY will be charged.
    3. If you did not provide us updated insurance information at the time of service AND your visit is rejected by Carefirst Blue Cross for that reason, it will be charged with in 30 days of your appointments. 

    * I authorize Frederick Psychiatry LLC to securely store my credit card on file.
    Yes
     
    No - I understand that by selecting this option, My appointment may not be confirmed with Frederick Psychiatry
     
    * I authorize Frederick Psychiatry to charge my credit card on file for any balance owed on the below indicated account, up to $150 per follow up visit and $250 for initial or Psychiatric evaluation visit.
    Yes
     
    No - I understand that if I have deductible on my account, My appointment may not be confirmed without this authorization
     
    * I agree that Frederick Psychiatry may charge my credit card on file. This authorization relates to all balances APPROVED by CAREFIRST BLUE CROSS but ARE MY RESPONSIBILITY. (This could be amounts resulting from balances related to copayment, deductible, co-insurance, or denials for no coverage or eligibility, but is not limited to these scenarios).
    Yes
     
    No - I understand that if I have deductible on my account, My appointment may not be confirmed without this authorization
     
    * I understand that this form is valid until I give a 30- day written notice to cancel the authorization to Frederick Psychiatry. Written notice must be submitted to Frederick Psychiatry.
    Yes
     
    No
     
    * I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form. If there was an error in information submitted to my insurance company, I will inform Frederick Psychiatry to resolve inconsistencies.
    Yes
     
    No
     
    * Card Details
    Card Holder's Name
     
    Last 4 digit of Card
     
    Expiration date
     
    * Type of Card
    Master Card
     
    Visa
     
    American Express
     
    Discover
     
    * To Authorize conditions for Payment Authorization to your Credit card.
    By checking this, you are eSigning this form.

    Credit Card Authorization for Payments

    * indicates a required field

    Frederick Psychiatry requires a method of payment for the portion of services APPROVED BY Carefirst Bluecross, but for which you are responsible, such as COPAY and DEDUCTIBLES. Your financial information is kept confidential and secure. A credit card method of payment is preferable.
    1. IF YOU HAVE NOT MET YOUR DEDUCTIBLE, payments to your card are processed on the day of appointment as specified below.
    2. If you have met your deductible, only your COPAY will be charged.
    3. If you did not provide us updated insurance information at the time of service AND your visit is rejected by Carefirst Blue Cross for that reason, it will be charged with in 30 days of your appointments. 

    * I authorize Frederick Psychiatry LLC to securely store my credit card on file.
    Yes
     
    No - I understand that by selecting this option, My appointment may not be confirmed with Frederick Psychiatry
     
    * I authorize Frederick Psychiatry to charge my credit card on file for any balance owed on the below indicated account, up to $150 per follow up visit and $250 for initial or Psychiatric evaluation visit.
    Yes
     
    No - I understand that if I have deductible on my account, My appointment may not be confirmed without this authorization
     
    * I agree that Frederick Psychiatry may charge my credit card on file. This authorization relates to all balances APPROVED by CAREFIRST BLUE CROSS but ARE MY RESPONSIBILITY. (This could be amounts resulting from balances related to copayment, deductible, co-insurance, or denials for no coverage or eligibility, but is not limited to these scenarios).
    Yes
     
    No - I understand that if I have deductible on my account, My appointment may not be confirmed without this authorization
     
    * I understand that this form is valid until I give a 30- day written notice to cancel the authorization to Frederick Psychiatry. Written notice must be submitted to Frederick Psychiatry.
    Yes
     
    No
     
    * I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form. If there was an error in information submitted to my insurance company, I will inform Frederick Psychiatry to resolve inconsistencies.
    Yes
     
    No
     
    * Card Details
    Card Holder's Name
     
    Last 4 digit of Card
     
    Expiration date
     
    * Type of Card
    Master Card
     
    Visa
     
    American Express
     
    Discover
     
    * To Authorize conditions for Payment Authorization to your Credit card.
    By checking this, you are eSigning this form.
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    Sanjeev Singhal MD

    I realize that Formatting changes from simple practice forms to posting as a text. Here is a link to form on website. 

    https://frederickpsychiatry.org/credit-card-payment-authorization/

     

     

    I realize that Formatting changes from simple practice forms to posting as a text. Here is a link to form on website. 

    https://frederickpsychiatry.org/credit-card-payment-authorization/

     

     

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    Gillian

    Sanjeev, thank you so much for sharing this template - I think that many in our community will find it useful. 

    Sanjeev, thank you so much for sharing this template - I think that many in our community will find it useful. 

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    Linda Walker

    This is great! Question: Is it possible to put this in the Consent Forms section of my Patient Portal and have these things electronically signed? 

     

    This is great! Question: Is it possible to put this in the Consent Forms section of my Patient Portal and have these things electronically signed? 

     

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    Gillian

    Hi Linda, absolutely - you can add a new Consent Form under My Account > Settings > Client Portal > Shared Documents and Files.

    Hi Linda, absolutely - you can add a new Consent Form under My Account > Settings > Client Portal > Shared Documents and Files.