Card on File Consent

 

For your convenience, we have implemented a policy which enables you to maintain your credit/debit card information on file with us. With your consent, this information will be securely held to cover future charges and additional fees.

Signing this consent in no way compromises your ability to dispute a charge or question your insurance company’s determination of payment.

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I hereby authorize May River Dermatology, LLC to keep my Card information on file for payment of any and all charges for medical services for which I am financially responsible within 30 days of the statement date. I further understand and authorize May River Dermatology, LLC to charge $100 for each missed appointment and $500 for any missed surgical appointment that is not cancelled within a minimum of 24 hours. 

I understand that you will send me a receipt reflecting any amount charged to my Card.

If my card information changes for any reason, I will notify you. This consent shall remain in effect until I provide written notification of termination.

Agreed to: