Patient Information – New “Card on File” Policy

To Our Patients,

We will be mandating a credit card on fiie policy beginning November \,2019. As you may be aware, the current healthcare market has insurers passing a large burden of healthcare expenses to you, the insured. Some insurance plans require large deductibles, co-payments, and co-insurances in amounts not knorvn to you or us at the time of your visit. Like hotels and car rental agencies that ask you for a credit card at the time of check-in, this policy is no different. We will hold your credit card, debit card, HSA card, or FSA card information electronically in a secure, approved, HIPAA-compliant Iocation with our credit card processor, Elevon, Inc. After your insurances processes and informs us of the amount you owe, we will send you an email informing you of your balance. We will charge your card on file for the balance due 5 days later. *

This card may be charged for the following reasons:

  • Visit payments not collected from you at the beginning of your visit
  • No-show or late cancellations of less than 24 hours’notice
  • Insurance discrepancies that are not resolved within 90 days from the date of service
  • Outstanding balances greater than 90 days past due

Fee Schedule Examples:

  • No-Show or late cancellations with less than 24 hours’ notice – $50**
  • Minimum charge to card on file per billing period- $5
  • Maximum charge to card on file per billing period – $1,500

This will make check-out easier, faster, and more efficient.

This will not compromise your ability to dispute a charge or question your insurance company’s determination of payment

We reserve the right not to see you for non-compliance with this policy.

If you have any questions, do not hesitate to ask.


Women’s Health Specialists

*If you wish to use an alternative method for payment of your balances, you may log into the portal and pay your bill online or call the office and we will take payment over the phone. This must be done prior to the date scheduled to debit your card on file.

** This applies to office visits only. Office procedures and Pelvic Floor Therapy appointments canceled without 24 hours’notice are subiectto a cancellation fee up to the cost ofthe procedure.