Credit Card on File Authorization Agreement "*" indicates required fields CompanyThis field is for validation purposes and should be left unchanged.Credit Card on File Authorization AgreementEffective Date: 5/30/2026Patient InformationPatient NameDate of Birth* MM slash DD slash YYYY Date* MM slash DD slash YYYY Account Holder Name (if different from patient):Credit Card on File Authorization Agreement Purpose of This Agreement This Credit Card on File Authorization Agreement (“Agreement”) explains how KS NP IN PSYCHIATRY AND FAMILY HEALTH PLLC may keep payment credentials on file or use a secure tokenized payment method through a third-party processor to charge authorized amounts related to services rendered and agreed fees. This policy is intended to: Simplify payment processing Reduce billing delays Support continuity of care Improve collection of patient-responsible balances Card-on-File Requirement The Practice may require a valid credit or debit card to be kept on file unless prohibited by law, payer contract, or a written exception approved by the Practice. The Practice may use a secure third-party payment processor to store card information or a payment token rather than storing full card details directly. Payment card information will be handled in accordance with applicable payment-industry security standards. The PCI Data Security Standard provides the baseline security requirements for environments where payment account data is stored, processed, or transmitted. Authorization to Charge Card By signing this Agreement, I authorize the Practice to charge the card on file, or the token associated with that card, for the following patient-responsible amounts: Time-of-Service Charges Copayments Coinsurance Deductibles Self-pay visit fees Deposits or prepayments authorized by the patient Post-Insurance Balances Balances remaining after insurance claim adjudication Denied, reduced, or non-covered charges that are the patient’s responsibility under the applicable health plan or financial policy Missed Appointment and Late Cancellation Fees No-show fees Late cancellation fees Other appointment-reservation fees permitted by law and clearly disclosed in the Practice’s financial policy Additional Authorized Charges Forms, letters, reports, and other administrative services Clinically billable communication charges, if separately authorized under Practice policy Returned payment fees, if permitted by law Balances previously invoiced and unpaid after reasonable notice Payment Processing Timeline The Practice may process charges as follows: Known copayments, self-pay fees, and deposits may be charged on or shortly after the date of service Post-insurance balances may be charged after the insurer has processed the claim and patient responsibility has been determined Missed appointment and late cancellation fees may be charged after the missed or late-cancelled appointment in accordance with the Practice’s written policy The Practice will make reasonable efforts to provide notice before charging larger balances, including through a billing statement, portal notice, text, email, or other customary communication method on file. Patient Notification The Practice may notify patients of charges or balances through: Patient portal Secure email Text message Mailed or electronic billing statement Telephone communication Failure to receive or review a courtesy notice does not eliminate financial responsibility for properly authorized charges. Declined, Reversed, or Failed Payments If a card transaction is declined, reversed, returned, or otherwise unsuccessful: The Practice may make a reasonable follow-up attempt to process the payment The patient or account holder may be contacted for updated payment information Future non-urgent appointments may be delayed, canceled, or placed on hold until the account is brought current, consistent with Practice policy and applicable law The patient remains responsible for valid balances owed. Any returned-payment or merchant-processing fee charged by the Practice must be permitted by applicable law and disclosed in the Practice’s financial policy. No-Show and Late Cancellation Authorization I authorize the Practice to charge the card on file for missed appointment and late cancellation fees consistent with the Practice’s written scheduling policy. No-show fee: $Late cancellation fee: $Required cancellation notice:business hours These charges are generally not billable to health insurance and remain the responsibility of the patient or responsible party. Security and Data Protection The Practice uses reasonable administrative, technical, and physical safeguards to protect payment information and may rely on a third-party payment processor for secure storage and transaction handling. The Practice may use tokenization or other methods designed to reduce the amount of payment card data retained within the Practice environment. PCI guidance recognizes tokenization as an approach that can help reduce exposure of cardholder data, though it does not replace PCI DSS obligations where those obligations still apply. The Practice does not guarantee that any electronic system is completely secure. Payment card data security is governed by payment card industry standards, while protected health information is governed by HIPAA; these are related but different compliance frameworks Disputes and Chargebacks If I believe a charge is incorrect, I agree to contact the Practice promptly so that the matter can be reviewed before initiating a charge dispute with my card issuer. Nothing in this Agreement limits any legal rights the patient or account holder may have under applicable law. However, improper or unsupported chargebacks may result in: a request for an alternative payment method suspension of non-urgent scheduling privileges referral of any valid unpaid balance for collection, if permitted by law and Practice policy Valid charges remain due even if disputed. Authorization Duration and Revocation This authorization remains in effect until the earliest of the following: the patient or account holder revokes it in writing the Practice terminates the authorization the account is closed and all balances are paid the payment card expires and is not updated Revocation must be submitted in writing to: KS NP IN PSYCHIATRY AND FAMILY HEALTH PLLC 820 Hempstead Turnpike, Lower Level Franklin Square, NY 11010 Revocation does not apply to: charges already incurred balances already due previously authorized missed appointment or service charges claims already processed showing patient responsibility If this authorization is revoked, the Practice may require another approved payment method before scheduling future non-emergency services. Updated Payment Information I agree to provide updated card information if: my card expires my account number changes my billing zip code changes the Practice requests updated payment credentials to process authorized charges Failure to maintain valid payment information may result in delayed scheduling or interruption of non-urgent services. Refunds If a refund is owed, the Practice will generally issue it to the original method of payment when feasible. Refund timing may vary depending on the card issuer, processor, and financial institution. Refunds are not generally issued for valid missed appointment fees or late cancellation fees unless required by law, payer contract, or an exception approved by the Practice. Compliance with Applicable Law This Agreement is intended to comply with: applicable state contract and consumer laws applicable federal healthcare billing requirements payment card industry security standards applicable to the Practice’s payment environment federal requirements regarding written authorization for certain recurring debit card charges where applicable If any provision of this Agreement conflicts with applicable law, payer contract, or regulatory requirement, that provision will be interpreted or limited to the extent necessary to comply, and the remaining provisions will remain in effect to the fullest extent permitted. Voluntary Agreement By signing below, I acknowledge and agree that: I have read and understand this Credit Card on File Authorization Agreement I have had the opportunity to ask questions I authorize the Practice to charge my card or tokenized payment method as described in this Agreement I understand that insurance verification is not a guarantee of payment I accept responsibility for all valid patient-responsible charges authorized under this Agreement I understand that payment card security standards and healthcare privacy laws are separate compliance frameworks and may both apply in a healthcare setting that accepts cards and handles health information SignaturePatient Name:Patient Signature:*Date: MM slash DD slash YYYY Cardholder / Responsible Party Name (if different):Signature:Relationship to Patient:Date: MM slash DD slash YYYY Practice Representative:Signature:Date: MM slash DD slash YYYY Card Information Section (Optional; only if consistent with processor workflow)Card Type: Visa MasterCard AMEX Discover Name on Card:Last 4 Digits Only:Billing Zip Code:
