Credit Card on File Consent Form

I hereby authorize Beal Wellness to securely store my credit card information on file and charge my credit card for all services provided to me by the clinic. I understand that the credit card on file will be automatically charged for any outstanding balance after insurance has paid their portion of the bill, with a maximum automatic charge limit of $250.

This credit card on file process allows me, the patient, to easily pay for all patient balances due, including copays, coinsurance, deductibles, and no-show fees. Once a week, Beal Wellness will review my account and charge any unpaid balances to my credit card on file. As a reminder, I may also choose to pay for services at the time of my appointment or via the patient portal.

I acknowledge that I may opt out of the credit card on file system at any time by notifying the clinic in writing or by phone. I also understand that I can request changes or updates to my credit card information at any time by contacting the clinic or billing department.

I acknowledge that my credit card information will be stored securely and in compliance with applicable laws and regulations, such as HIPAA and PCI DSS. I understand that the clinic has policies in place to protect my personal and payment data and to respond appropriately to any breaches or issues related to data security.

I understand that the clinic has a refund policy in place. This policy applies to charges made to my credit card on file, and I may request a refund for any overpayments or for services that were not provided to me.