Dental office credit card authorization form

Credit Card on File Authorization. Please complete this form if you would like. McCracken Family Dentistry to keep your credit card on file for future payments. You may elect to provide us with credit card information separately for each payment.

PDF download: Publication 5– Internal Revenue Service. You can help bring … child. Fees paid by credit card are subject to a statutorily authorized. Any unauthorized duplication or use of PowerPay for Easy Dental in …. The Consent Forms allow patients to authorize credit card payments for the … The Consent Forms authorize your office to charge the credit card for services rendered.

This letter is to finalize our financial agreement for uninsured services, Dental fees and late payments on your account. Basically, it is a legal document duly signed by the cardholder to give permission to the retailer to charge the credit card for the purchase of goods or services. The form does two things: It mitigates the risk of customers saying they were charged when they shouldn’t have been, and it saves everyone a lot of time.

The dental patient consent form is used for any type of oral surgery or treatment in order to hold the dentist harmless of any wrong-doing (unless there is evidence of malpractice). The form should be signed by the patient before any medication or medical. At the beginning of treatment, we request you secure your account with a credit card.

This card will only be charged with your permission below. Our fees are based on the quality materials we use and the time, effort and skill required in performing your treatment. Most dental offices are not aware that they can set up pre-authorized payment by credit card with their patients.

It is not only possible, but very easy to do! Visa and MasterCard have developed a consent form. A credit card authorization form is an official document. The cardholder signs the document to grant permission to the merchant. Then the merchant can charge a fixed amount on the card for a specific amount of time.

Such form is typically used by business. This form is a life savior for everyone including customer, bank, and merchant. This can either be for a 1-time charge or recurring (weekly, monthly, etc). The form is often used to give businesses the ongoing authority to charge the cardholder on a recurring basis — whether that’s monthly, quarterly, or more sporadically.

I am legally authorized to give permission for its use to your dental office. I understand that once the treatment gets starte our dental office will not be entitled to any refunds and that I agree not to dispute the resultant charges. Our primary mission at Capitol Hill Dental Clinic is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering payment options.

Recurring Payment Authorization Form Schedule your payment to be automatically charged to your Visa, MasterCar American Express or Discover Card. Just complete and sign this form to get started! Here’s How Rainier Care Recurring Payments Work: You authorize regular monthly charges to your credit card.

It is essential that some designated body authorizes the credit disbursement. This process is often carried out through the credit authorization form. Today, over percent of the dental practices in the U. In my opinion, this is a very effective payment option and the few offices that are not accepting credit cards certainly should.

Below are some suggestions to help your office increase payment by credit card. This is a payment option that benefits the patient and practice. The following form is a generic authorization for credit card use form. The authorization is does not indicate a defined period. How can I trust that you will keep my credit information safe?

We use a secure gateway called Transfirst that is completely compliant as required by law. Most dental practice management experts these days agree that the most successful practices will routinely provide five-star customer service to their patients.