Credit Card Authorization

Credit card on file billing authorization FAQ

Q: How does the automatic billing process work?

A: Your credit card will be captured today and stored securely. After your insurance carrier responds and provides us your remaining balance due we may charge the patient responsibility to your credit card. Your credit card on file will only be charged when you have a balance owing on your account or for a non-covered service.

Q: How will I know how much you are going to charge me?

A: You will receive an explanation of benefits from your insurance carrier that explains exactly, according to your health insurance coverage and benefits, how much of your healthcare bill is your responsibility and how much the insurance paid along with any contractual adjustments.

Q: What if I need to dispute my bill?

A: We will always work with you to resolve any issues and will refund you if we have made a billing error. We will only charge you the amount that we are instructed by your insurance carrier to collect from you in the same way that we normally determine how much to send you a statement for in the mail. If you disagree with how your insurance carrier processed the claim, you will need to contact their customer service department directly.

Q: Will I receive a statement or receipt for the charges automatically billed to my card?

A: Not automatically. Your insurance carrier EOB and your credit card statement will be your receipt. You can at any time contact us to have an account itemization emailed to you.

Q: What is a deductible?

A: An annual deductible is the dollar amount you must pay out of your own pocket during your plan year for medical expenses before your insurance begins to pay. For example, if the policy has a $1,000 deductible, you must pay the first $1,000 of medical expenses before your insurance will begin to pay. Your insurance company must receive a claim to process in order to apply balances towards your deductible. Even if you have a high deductible plan, we encourage you to have us submit the claim to your insurance so you receive a contractual adjustment and the services can be applied towards your deductible.

Q: Is my credit card secure? A: Yes, we do not store your sensitive credit card information in our office. Keeping your card on file, offsite, in an encrypted payment gateway actually enhances security because it reduces exposure at each visit.

Hidden

Credit Card Authorization Form

Arizona Allergy Associates is offering a secure and convenient method of payment for the portion of services that your insurance does not cover, but for which you are liable. Your credit card information is kept confidential and secure. Payments to your card are processed only after the claim has been filed to and processed by your insurance carrier and the insurance portion of the claim has posted to your account, or in the event that valid insurance information was not provided at the time of service.

Credit Card Athorization

I authorize Arizona Allergy Associates to capture my credit card information and securely store my credit card on file. I realize I will not receive a statement or a receipt and my insurance EOB and credit card receipt will be my notification. I may request one from the billing office after payment has processed.

I do not authorize Arizona Allergy Associates to store and charge my credit card.

I authorize Arizona Allergy Associates to charge my credit card on file for any balance owing on the account identified below.

I agree that Arizona Allergy Associates may charge my credit card on file for any balance due when they receive a copy of the EOB or within 30 days for any other balance due on my account. This authorization refers to all balances not covered by my insurance company for services rendered by Arizona Allergy Associates. These could be amounts resulting from balances related to copays, deductibles, coinsurance, non-covered services, non-coverage / eligibility denials, or fees, but are not limited to these scenarios.

I understand that this form is valid until I give a 30-day written notice to cancel the authorization to Arizona Allergy Associates.

Written notice must be submitted to: Billing Office, 705 S Dobson Rd, Chandler, AZ 85224

I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form.

Patient Name(Required)

First Last

Card Holder’s Name (as shown on card)(Required)

Credit Card(Required)

Visa

MasterCard

American Express

Discover

Last Four Digits of Credit Card(Required)

Expiration Date (mm/yy)(Required)

CVV No:(Required)

(3 digit Security Code)

Billing Address:(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Cardholder Signature:(Required)

Date:(Required)

Credit card on file billing authorization FAQ

Credit Card Authorization Form

MAKE AN APPOINTMENT

Find a clinic near you

Call for an appointment

Feel free to message us

About Us

Locations

Our Services