In order to keep our treatment costs and clerical fees down, we require a credit or debit card number on file.  This credit card number will only be used if there is an outstanding balance in your ledger not paid by you or your insurance company upon resolution of your insurance claim.  We will be courteous and mail you a receipt upon posting these charges.

I, the undersigned, authorize Dr. Grandi or its billing service provider, Flatirons Practice Management, to retain on file the credit/debit card that I provided and to charge this credit/debit card for services rendered upon resolution of my insurance claim and am thereby agreeing to pay amounts due and owing according to the card issuer agreement (merchant agreement if credit voucher).