Secure Forms

Credit Card Automatic Payment Authorization Form

Here’s How Automatic Payments Work:

By signing this form: you authorize Pediatric Professional Association to charge your Visa, MasterCard, American Express or Discover card. You will be charged at least 29 days after Pediatric Professional Association posts the Explanation of Benefits/Payments for anything deemed: patient responsibility, noncovered, or denied by the insurance company. The charge will appear on your credit card statement and the receipt will be available via the patient portal. You agree that no prior-notification will be provided if the total payment is under $100 per patient. If the individual patient bill is more than that amount you will receive notice from us at least 1 day prior to the payment being collected. Please note: the health insurance policy is a contract between the policyholder and the insurance company. It is your responsibility to know the benefits, as well as if PPA is in-network and participates with the insurance company. We will attempt to bill the insurance company for all services rendered in our office. Any denied services or any balance remaining following adjudication of the claim is your responsibility. You have the ability to set up a payment plan, however you must contact PPA’s Business Office and have it approved by PPA, prior to the 29th day of PPA posting the EOB.

Please complete the information below:


I  
authorize Pediatric Professional Association to charge my credit card.

The card will be used for automatic payments for the patient account(s) listed below:





Today
I authorize Pediatric Professional Association to charge the credit card indicated in this authorization form according to the terms outlined on page 1.I understand that this authorization will remain in effect until I cancel it in writing. I agree to notify Pediatric Professional Association in writing of any changes in my account information or termination of this authorization. I certify that I am an authorized user of this credit card and that I will not dispute the automatic payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.