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Credit Card Authorization Form
Here is a fantastic form that gives you permission to charge balances not covered by insurance directly to your patients’ credit card. This has been working remarkably well and has been shown to increase profits like crazy! Feel free to customize it to your office. Note: If any debt is over thirty days old and all efforts have failed, we STRONGLY suggest that you send the “Statement of Delinquency” form.
Credit Card Authorization Form
I ____________________________ hearby authorize Dr. Fuddrucker to submit electronic claims on my behalf and agree to assign the payment directly to Dr. Fuddrucker. I understand that my insurance is an agreement between the insurance company and myself. I further understand that I am responsible for any service fees or balances that may not be covered by my dental benefits plan and any differences resulting from the amount billed and the amount covered by my plan. I authorize the following credit card to be billed for any outstanding balances.
Signature: ____________________________
Patient Name: ____________________________
Responsible Party (if different than patient): ____________________________
Please circle credit card: Visa MasterCard Amex
Date: ______________________________
Phone #:____________________________
Card #: ____________________________ Expiration Date: ____________________________
Card holder signature: ____________________________ CC security code: ____________________________
Print name: ____________________________ Date: ____________________________
Staff Initials: __________
