Consent for Recurring Credit Card Payments
I (“the patient”) agree to allow Form Health Associates (MA), P.C. and the members of its Affiliated Covered Entity (collectively “Form Health Associates,”), Healthy Life Physicians Group Pacific Northwest, P.C., and Form Associates, P.A. (collectively, “Form Health”) to securely store a credit / debit card (the “payment method”). The patient authorizes the payment method to be used automatically for any patient responsibilities for payment. If a credit card account is being used for a transaction, Form Health may obtain preapproval for an amount up to the amount of the payment. If the patient wants to designate a different payment method or if there is a change in the patient’s payment method information, the patient must change the information online. This may temporarily delay the ability to make online payments while we verify the new payment information.
If the patient purchases a subscription to Form Health’s products services, the patient’s subscription is continuous and will be automatically renewed at the end of the applicable subscription period, unless the patient cancels his or her subscription before the end of the then-current subscription period by clicking here. If the patient cancels his or her subscription, the patient’s account will automatically close at the end of the current billing period. Form Health may change the price for the patient’s subscription, from time to time and will communicate any price changes to the patient in advance and, if applicable, how to accept those changes. Price changes will take effect at the start of the next subscription period following the date of the price change. Subject to applicable law, the patient accepts the new price by continuing to use the Form Health products and services after the price change takes effect. If the patient does not agree with a price change, the patient has the right to reject the change by unsubscribing from the services or products prior to the price change going into effect.
The patient represents and warrants that (i) any credit / debit card information the patient supplies is true, correct and complete, (ii) charges incurred by the patient will be honored by the patient’s credit/debit card company, (iii) the patient will pay the charges incurred in the amounts posted, including any applicable taxes, and (iv) the patient is the person in whose name the credit / debit card was issued and the patient is authorized to make a purchase or other transaction with the relevant credit / debit card and information.
The patient agrees and authorizes the payment method to be billed automatically for the entire visit, according to the published pricing on the Form Health website, which is subject to change at any time.
If Form Health is unable to secure funds from the patient’s debit / credit card(s) for any reason, including, but not limited to, insufficient funds in the debit / credit card or insufficient or inaccurate information provided by the patient when submitting electronic payment, Form Health may undertake further collection action, including application of fees to the extent permitted by law.
The patient has the right to revoke this authorization by contacting Form Health via firstname.lastname@example.org at least fifteen (15) days prior to the scheduled payment date. The patient understands and acknowledges that services may be cancelled or withheld if the patient revokes this authorization, and that patient is still responsible for all charges incurred by the patient or otherwise owed to Form Health This authorization will remain in full force and effect until revoked by the patient or Form Health.
The patient acknowledges and agrees he or she will not dispute the payment with the credit / debit card company, provided the transactions correspond to the terms indicated in this authorization form.