CREDIT CARD ON FILE POLICY

 

Back To Basics Pediatrics, SC has updated our billing practice regarding receiving patient payments.  Effective 2/13/2021, we require a credit card, debit card or HSA card to be kept on file with our office.  

 

Once your claim has been filed and processed by your insurance carrier, if you are left with a balance due, our office will send you an invoice.  Upon receipt of the invoice, you can call the office to use your card on file, mail in a check or pay on the patient portal.  After 30 days, if the balance remains on your account and that balance is under $50, we reserve the right to automatically use your card on file to pay your balance.  We will email you a copy of the receipt. 

 

NO SHOW appointments will be charged a $25 fee for the first time.  A $50 no show fee will be charged for repeated missed appointments with the possibility of being discharged from the practice.

 

 

X__________________________________________

Signature of patient or personal representative

 

Date____________________

 

 

*Your credit card information is not kept on file in this office.  It is kept securely offsite by our Payment Gateway and our office does not have access to your full credit card number once it is entered into our system.