WITH confirmed eligibility at check-in: After Hour Pediatrics Urgent Care Clinic (AHP) will electronically scan the authorized credit/debit or HSA/FSA card into AHP’s secure credit card system. You may call at any time to update or change this card. All cards are encrypted and we can only view the last 4 digits of your card and the expiration date.
The insurance company will send an Explanation of Benefits (EOB) to AHP and to the insured. AHP may receive the EOB before the patient. This EOB will explain whether a balance is due to AHP or if a refund is due to the patient. All EOB’s can be accessed on line by the insured or by calling the insurance company. The number is on your insurance card. We process credit cards upon receipt of the EOB.
This signed authorization covers charges made by AHP to your credit card due to:
(1) A deductible that has not been satisfied and is your responsibility
(2) A co-pay or co-insurance that your insurance assigns as your responsibility and/or
If a refund is due, it will be processed back to your card as we enter your EOB. It is our policy not to hold any overpayments on accounts. Many times you will see a charge made to your card and this is due to the fact that your copay for urgent care visits is higher than the regular office visit copay. You may confirm the amount with your insurance company. The amount charged/refunded should match exactly the amount of the “patient responsibility” portion on the EOB provided by your insurance company.
WITHOUT confirmed eligibility at check-in: If insurance eligibility cannot be confirmed at check-in,
AHP requires a credit card on file and a deposit of $199.00, which will be held for 10 business days while we work with you to obtain benefits and eligibility so that we can bill on your behalf. If you are eligible for insurance benefits, we will bill the insurance company and you will be refunded the $199 less your assigned responsibility.
If the insurance company determines non-eligibility, the credit card will be charged full service rates.
If you have questions about your charges we are always willing to discuss with you. You may contact AHP billing at 650-579-6581 option 3 or ahpsanmateo@gmail.com. If you reverse a credit card charge, AHP charges a cancellation fee of $25 per charge in addition to your regular fee.
I authorize AHP to keep my credit/debit card information and signature on file in order to charge my credit/debit card for balances due. This Credit Card Authorization/Credit Card On File Policy will remain in effect until notified by responsible party in writing.
I understand statements are not sent by AHP, my EOB serves as a statement of my responsibility and I agree to keep my account current and in good standing.