Bloom Pediatrics requires that a valid Credit Card be kept on file (debit card not recommended). This policy applies to each child within a family.
The policy is designed to:
• Help avoid all billing related fees
• Streamline the billing process and eliminate the expenses related to handling overdue accounts
• Focus our time and energy on your children and their medical care
The card information is stored electronically in an encrypted form and cannot be viewed by our team.
How the policy works:
1. At the time of your registration or check-in, you will be asked for your credit card information to be electronically stored in encrypted form on our computer. Only the last four digits are visible to our staff.
2. We will bill your insurance carrier as a courtesy for all charges related to the visit.
3. After receiving an EOB from your insurance company, a statement will be generated to the address on file for your records/review. After this statement has been generated, a separate letter will then be sent notifying you of the amount we intend to charge to your credit card on file. The credit card on file will be processed 14 days after the date on this letter, should the balance remain unpaid.
4. Coordination of benefits are the responsibility of the insurance holder. The credit card on file will be charged if the coordination of benefits is not completed and the account becomes past due.
5. If we attempt to use your card and it is declined or has expired, we will send you a new statement with a note attached asking for current credit card information.
Please remember that this policy does not restrict your right to appeal any charge made to your credit card. If you feel we have charged your card in error, contact our office ASAP. If a mistake has been made, we will reverse the charges.
My signature below certifies that I have read and consent to the Credit Card on File policy. I agree to provide my credit card information to Bloom Pediatrics for the sole purpose of payment for my child(ren)s medical care. I have the right to cancel this process and use another form of payment.
Until further notice, I authorize Bloom Pediatrics to charge the patient-responsible balances on my account.