Credit Card Agreement

We have implemented a new, convenient payment policy using a credit card on file, to streamline our billing and payment system and to provide a seamless, convenient way for patients to pay their copayments, deductibles, & bills.

ALL PATIENTS, new and existing will be asked for a credit card at the time of your appointment, and this information will be held securely. The amount that we will charge to the credit card on file will be the financial responsibility that the insurance company requires you to pay. Credit card information will be protected and stored via our HIPAA compliant, processing card portal.

Cards on file will be used for deductibles, copayments, and any outstanding balances that have been discussed with the patient. Any deductible or copayment amount that is patient responsibility will be processed at the time of service.

By signing below, I agree to all of Embracing Life Wellness Center’s Credit Card on File Policy and I authorize Embracing Life Wellness Center to keep my signature and a valid credit/debit card number securely on-file in my account. I allow Embracing Life Wellness Center to automatically charge my credit card at the time of my appointment for deductibles, copayments, & balances if applicable.

If the credit card that I give today changes, expires, or is denied for any reason, then I agree to immediately give Embracing Life Wellness Center a new, valid credit card which I will allow them to key-in over the phone. Even though Embracing Life Wellness Center is not swiping this card in person, I agree that the new card will still be subject to the financial policy listed here and may be used with the same authorization as the original card which I presented in person.

I understand that I am responsible for payment for all services provided to me by Embracing Life Wellness Center. I understand that this form is valid until I cancel this authorization through written notice to Embracing Life Wellness Center.

By electronically signing this form, patient and/or guardian if patient is a minor, agrees and consents to all of the above terms and policies.