Which Option is Correct?(Required) I have never submitted a Credit Card Authorization Form to Holsitic Health Associates I have previously submitted a Credit Card Authorization Form and would like to update it Please complete all fields.  You may cancel this authorization at any time by submitting a signed request to do so. This authorization will remain in effect until cancelled.OptOut(Required) By signing below, I am declining to keep a credit card on file with Holistic Health Associates. As a result, I understand that I will be financially responsible for the full self-pay amount of the scheduled service. I understand I must pay for my service prior to the service being rendered. I understand that if HHA will be processing my claim to my private insurance, I am responsible for the full patient responsibility balance determined by my insurance company and that I am responsible for the full self-pay amount of the scheduled service if my claim is denied.(Required)Signature of Patient, Legal Representative, or Parent/Guardian(Required)By completing this box, you have digitally signed the Holistic Health Associates Credit Card Authorization Opt Out formDate(Required) Month Day Year Printed Name of Patient, Legal Representative, or Parent/Guardian(Required)Relationship to Patient By signing below, I am declining to keep a credit card on file with Holistic Health Associates. As a result, I understand that I will be financially responsible for the full self-pay amount of the scheduled service. I understand I must pay for my service prior to the service being rendered. I understand that if HHA will be processing my claim to my private insurance, I am responsible for the full patient responsibility balance determined by my insurance company and that I am responsible for the full self-pay amount of the scheduled service if my claim is denied.Update or Replace Current Card on File?(Required)Please advise if HHA should Update the existing card on file or replace it with the card listed on this form Update Replace What are the last 4 digits of the credit card currently on file with us that you are wishing to replace?(Required)Cardholder Name(Required) First Last Name (if different than cardholder name) First Last Date of Birth(Required) Month Day Year Card Number(Required)Expiration Date(Required)CVC Code(Required)Card Type(Required) Visa Master Card American Express Discover Billing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required)This card will be used for any and all balances on your account. If there is any specification needed (i.e. to use a different form of payment, or a different card for a specific service or charge, or any modifications to your card on file, etc.) please check out IN PERSON with the Front Desk each time this is needed. The Front Desk is not responsible for remembering or tracking each patient’s accounting preferences.Is this an HSA or FSA card?(Required) Yes (an additional NON HSA/FSA card is required to be kept on file) No Additional Card on File (if applicable) When using an HSA or FSA, Holistic Health Associates requests you keep an additional card on file for herbs and non-service related expenses, as well as in the event your HSA funds run out. You may also elect to keep an additional card on file for specific purchases but are responsible for notifying the Front Desk when you would like to use this card to pay for specific items.Cardholder Name (as shown on card) (Additional Card on File (non-HSA/FSA))(Required) First Last Card Number (Additional Card on File (non-HSA/FSA))(Required)Expiration Date (Additional Card on File (non-HSA/FSA)(Required)CVC Code (Additional Card on File (non-HSA/FSA))(Required)This/These card(s) is/are approved for the following additional patients/accounts: Add RemoveBy listing additional names here, you authorize Holistic Health Associates to take payment on these respective accounts for any services rendered, purchases and/or balances with the credit card listed above.Retaining Credit Cards on File Our office requires retention of an active credit or debit card on file via Credit Card Authorization form. We may use this card on file to bill any balances indicated as patient responsibility by your insurance, if applicable, or to reconcile any balances beyond 30 days. Health Savings and Flexible Spending cards are acceptable forms of payment; however, we will require an additional card on file in case the available funds on those cards have been exhausted, or it is restricted by the services rendered to you. All credit card information is encrypted and stored securely and is not shared with any third party. If you elect not to keep a credit card on file with our office, you must pay for your services in full, prior to the services being rendered, regardless of if you are using private insurance to process your claim. There are no exceptions. Any patient credits that are a result of claims processing will be applied to your account to use towards future balances (copays, coinsurance, services and/or products) or can be refunded to you upon request. Cancellation Fee An appointment reserves time in our office. To ensure that the maximum number of patients can receive care when needed, we require notification of any appointment changes 24 hours in advance of your appointment. A $65 fee will be assessed for any missed appointments or cancellations with less than 24-hour notice. Electronic Appointment Reminders via text and email are sent as a courtesy and inability to receive one is not an excuse to miss an appointment. Ultimately, it is the responsibility of the patient to keep track of their appointments. Disputing cancellation fees or non-adherence to office policies could result in scheduling privileges being revoked. By signing below, I authorize Holistic Health Associates to charge my credit card above for services rendered, purchases and/or balances as outlined in the Financial Policy and/or in this document. I understand that my information will be securely saved to file for future transactions on my account.Signature(Required)Consent(Required) By signing below, I authorize Holistic Health Associates to charge my credit card above for services rendered, purchases and/or balances as outlined in the Financial Policy and/or in this document. I understand that my information will be securely saved on file for future transactions on my account.Signature of Patient, Legal Representative, or Parent/Guardian(Required)By completing this box, you have digitally signed the Holistic Health Associates Credit Card Authorization form.Date(Required) MM slash DD slash YYYY Printed Name of Patient, Legal Representative, or Parent/Guardian(Required)Relationship to Patient(Required)
