CREDIT CARD / ACH PAYMENT AUTHORIZATION FORM
Forest Orthodontics and Pediatric Dentistry offers a secure and convenient method of payment for the portion of services that insurance doesn’t cover, but for which you are liable. Your credit card / ACH information is kept confidential and secure.
Credit Card Information - Please complete all fields:
Credit Card Information - Please Check Card Type:
VISA
MASTERCARD
DISCOVER
AMERICAN EXPRESS
Cardholder Name (As shown on card):
Card Number:
Expiration Date: (mm/yy):
Security Code (CVV 3 Digits):
Billing Zip Code:
Email:
OR:
Account Information- Please complete all fields:
Please check account type: Checkings / Savings
Account Holder Name:
Bank Name:
Routing Number:
Account Number:
Email:
I
authorize Forest Orthodontics and Pediatric Dentistry to charge my credit card/ ACH account for co-pays, coinsurance, and deductible amounts
not collected at the time of service. If I am using my insurance benefits or I am a private pay client of the practice, Forest Orthodontics and Pediatric Dentistry requires the account to be kept on file. This is due to high incidence of unreported deductibles and the fact that insurance may not cover certain services rendered leaving a remaining balance, which is the patient’s legal responsibility. In addition, I authorize Forest Orthodontics and Pediatric Dentistry to charge my account for any outstanding account balances following insurance determination. I understand that my information will be saved on file for future transactions on my account. I also understand that account charges may not coincide with scheduled appointment dates.
By paying via credit card/ ACH account, I acknowledge that this information will be automatically kept on file using PCI-compliant encrypted code through the following payment processor: Global Payments Integrated. Health Savings Account (HSA) or Flexible Spending Account (FSA) cards may also be kept on file as the primary form of payment. However, I retain the right to request the removal of any account from file via written request. Receipts and statements will be available upon written or verbal request. By signing below, I certify that I am the authorized user of this account and authorize Forest Orthodontics and Pediatric Dentistry to store my account information on file.
Patient(s) Name
Patient or Patient/Guardian Signature
Draw your signature in the box below with your mouse or cursor.
Date Signed: