Credit Card Authorization

Please fill out this form as completely as possible. It will be sent securely to our office.

Thank you for choosing Fairhope Pediatrics as your child’s medical home. We are committed to providing you with exceptional service. Each year, insurance companies are shifting more costs to families. We are adding a new service to help families manage these health care expenses.

Just like your telephone or cable bill, you can now put a credit card on file to pay your Fairhope Pediatrics balance automatically after all insurance payments and adjustments have been made. We will bill your insurance company first and upon their determination of benefits, we will only charge your credit card on file when they inform us of your responsibility. Circumstances when your card would be charged include but are not limited to uncollected copays, coinsurance, deductible, any non-covered services, and/or denial of services.

Once your insurance has processed your claims, an Explanation of Benefits (EOB) will be available to both you and our office showing the amount of your responsibility. You will typically receive the EOB before we do, so if you disagree with the patient responsibility, please contact your insurance carrier immediately.
When we receive the EOB, we will apply any payment/adjustment information to your account. A statement will be sent the following billing cycle and your credit card on file will be charged 21 days later. This will allow you to review and call Fairhope Pediatrics billing department to ask any questions.

If the credit card on file becomes invalid, please notify Fairhope Pediatrics immediately. If for some reason we are not notified of any changes and the credit card on file is declined, we will attempt to reach you to update the information. If we are unable to reach you, a surcharge of $25.00 may be applied to your account. This information will need to be updated prior to scheduling any future appointments.

Should there be an adjustment regarding a claim, we will promptly reimburse you the portion that is due back to you.

"*" indicates required fields

Patients

You can list up to six patients.

Patient Name*

DOB*

Patient Name 2

DOB 2

Patient Name 3

DOB 3

Patient Name 4

DOB 4

Patient Name 5

DOB 5

Patient Name 6

DOB 6

Credit Card on File Authorization

By signing below, I agree to Fairhope Pediatrics’ credit card on file policy and I authorize Fairhope Pediatrics to keep my signature and valid credit/debit card number securely and confidentially encrypted on file.

Name on Card*

Card Type*

Card Number*

Expires*

CVV*

Billing Address*

Billing address is the same as physical address

Billing address is different from physical address

Billing Address*

Billing Email*

Signature*

Hidden

Date

Comments

This field is for validation purposes and should be left unchanged.

Credit Card Authorization

Patients

Credit Card on File Authorization

Connect With Us

Fairhope Pediatrics

Office Hours

By Appointment Only

After-hours Care

Newsletter