Please print this form , sign and fax to 305 445-2691 or email to frontdesk@miamiurgentcare.com
Credit Card Authorization Form. Every insurance policy contains copays, coinsurance, deductibles etc. that the patient is responsible for when you visit our medical office. We do our very best to ESTIMATE the portion of your bill that you are responsible for at the time of your visit and inform you of those fees before we provide those services. We will then collect this ESTIMATE from you at the time of your visit. We utilize various sources to try and confirm your eligibility and the portion of your fees that you are personally responsible for. These include online resources and phone calls to your insurance company. In spite of our best efforts those ESTIMATES may turn out to be lower or higher than your true cost. The actual portion that you are responsible for can only be determined after we submit the claim to your insurance company and we receive back from them the Explanation of Benefits that explains to us the insurance company's responsibility and the portion you are responsible for in detail based upon your specific contract with the insurance company. After we receive this Explanation of Benefits we can accurately determine whether you owe additional money to us or are due a refund from us. You will receive a copy of your Explanation of Benefits directly from your insurance company as well. As a result of this we require keeping your credit or debit card on file as a convenient method of payment for the portion of services that your insurance doesn?t cover, but for which you are responsible or for us to refund any amount that you have overpaid. Your credit card information is kept confidential and secure and payments to your card are processed only after the claim has been filed and processed by your insurance company. I authorize Dr. Harris Mones, Miami Urgent Care and / or Alhambra family Practice to charge the portion of my bill that is my financial responsibility up to the amount of $150.00 or to credit any money owed back to me, to the following credit or debit card. If the amount that I am responsible for for any one visit is greater than $150.00 I understand that my card will be charged $150.00 and that a representative from the medical office will contact me personally to obtain verbal approval for the charges exceeding $150.00 prior to charging my credit card any additional amount. I,____________________________________________ agree disagree to allow Dr. Harris Mones / Alhambra Family Practice / Miami Urgent Care to charge my credit card on file for any remaining balance I owe or to credit my card for any credit balance owed to me once they receive the Explanation of Benefit from my insurance carrier. I have read this Financial Policy and I agree to the terms and conditions outlined within this policy. I hereby consent to medical care and treatment as deemed necessary and proper by the medical staff of Dr. Harris Mones / Alhambra Family Practice Center / Miami Urgent Care. Furthermore, I agree to assign all health insurance benefits directly to Dr. Harris Mones / Alhambra Family Practice Center / Miami Urgent Care. and understand that I am responsible for any costs not covered by my health insurance. This authorization will remain in effect until I (we) cancel this authorization. To cancel, I(we) must give a 60 day notification to Dr. Harris Mones / Alhambra Family Practice Center / Miami Urgent Care] in writing and the account must be in good standing.<br/>
