FINANCIAL POLICY AGREEMENT

SOL MEDICAL GROUP

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Debit/Credit Card on File Policy
We have implemented a convenient payment policy using Credit Card on File. As you are aware, the
current state of healthcare in our market has resulted in significant changes in insurance policies, copays,
deductibles, and premiums. Unfortunately, a great deal of the financial burden now falls on the patient.
There are insurance plans that require deductibles and copayments in amounts unknown to you, or to us,
at the time of your visit. You will be asked for a debit/credit card at the time you check in to leave on file
in your patient chart. This information will be held securely. The amount that we will charge to the card
on file will be the financial responsibility that the insurance company requires you to pay.
Q & A- Card on File
What are the benefits for me? Patients who have a card on file will no longer have to worry about
statements and mailing in payments. You can also use it to pay for future visits without having to bring
your card. Having a card on file will make check in easier, faster, and more efficient for patients.
How does this work? During your visit, we will ask you to sign a “debit/credit card on file agreement”.
When our office receives remittance advice/information from your insurance company (typically 2-4
weeks), any remaining portion of charges will be charged to your card. We will notify you FOUR TOO
FIVE DAYS BEFORE the charge is due to take place, and you may call our office if this presents a
problem/hardship for you. A receipt can be either emailed, texted or picked up at your next visit. If the
payment is declined, we will request updates card information or us an alternative form of payment.
How can I assure my card information will remain safe? Under HIPPA, we are under strict state and
federal rules and guidelines to protect patient privacy and the card is considered protected health
information. We will store your information on a secure and encrypted sire, which will enable us to run
bank transactions through our company computer system.
I never had to do this at any other doctor’s office: This may be different from what you have been
used to, but it is becoming common practice in most health care facilities with the changes that have come
about in the insurance industry. Many practices now require a card on file, and payment at the time of
service. This policy is being instituted, to simplify and enhance your patient experience. This change will
lower the practice’s administrative expenses to allow us to focus more on providing the exceptional
patient care that you have becomes used to at SOL Medical Group. ** The Law may require confidential
epidemiological reporting. It is the intention to comply with applicable laws and regulations.