Credit Card on File Policy

We are always seeking ways to improve our efficiency and service as your area’s leading urgent care provider. We have instituted a “credit card on file” system to allow smoother transactions and billing for your visits.

It is our policy to collect all co-payments at the time of service. Additionally, we require a credit or debit card from you for any future balance you may be responsible for from today’s visit. Please provide the front desk staff with your photo ID, your insurance card, and your method of payment. At least five (5) calendar days before your credit card is charged (if applicable), you will receive an email notification informing you of the balance that is your responsibility to pay. Should you have any questions regarding the remaining balance due, please contact our center. AFTER FIVE (5) CALENDAR DAYS, YOU WILL BE CHARGED THE REMAINING BALANCE ON YOUR ACCOUNT FOR THIS DATE OF SERVICE.

AFC does not retain your actual credit card information on file. we use a payment card industry compliant merchant services processor who provides our system with an encrypted token or reference to your card. Your card details are not visible to our staff nor are they available in our system. We only have visibility to the encrypted token and the fact that we have obtained this authorization per this agreement from you.

After today’s visit, we will submit a claim to your insurance carrier. Once your insurance carrier has processed the claim, they will provide you with an Explanation of Benefits (EOB); your insurance carrier will then notify us of the payment amount for which you are responsible. We will only process a charge if your insurance carrier leaves you with a balance. Charges will be for the exact amount due.

This process is rapidly being adopted in the healthcare industry. If you have any questions about this policy, please do not hesitate to contact our Customer Service team and we will be happy to promptly respond to your inquiry.

I, the undersigned, authorize and request that my card be on file and to charge my credit/debit card to for balances due for this date of service for services rendered on this date of service that my insurance company identifies as my financial responsibility. This authorization relates to all balances for services provided to me by AFC on this date of service and will remain in effect until the charges for this date of service are paid in full.

FAQ

Why is AFC utilizing this policy?

Its purpose is to guarantee payment for services rendered that may not be completely covered by insurance including services applied to a patient’s deductible.

How will I know how much you are going to charge me?

After today’s visit, we will submit a claim to your insurance carrier. Once your insurance carrier has processed the claim, your insurance carrier will provide you with an Explanation of Benefits (EOB); your insurance carrier will then notify AFC of the payment amount for which you are responsible. Once we are notified by your insurance carrier of this amount, we will send you an email to inform you of any balance due. We will only process a charge if your insurance carrier leaves you with a balance. Charges will be for the exact amount due.

How can I trust that you will keep my credit card information safe?

We do not keep any credit card information on file in the clinics, corporate office, or any computers within our Company. We use a secure, encrypted gateway site that is completely compliant as required by law. Staff, billing personnel, and corporate officers are not able to see your credit card sequence as it is saved under a token ID number. After you receive your credit card back from our front desk staff, the information is no longer available to us.

What if I need to dispute my bill?

We will always work with you to understand if there has been a mistake and we will refund your card if we have made a billing error. We will only charge the amount that we are instructed to by your insurance carrier in the EOB they send to us. This amount is exactly the amount we would have traditionally sent you a paper patient statement for in the mail. If you have any questions about your coverage, please contact your insurer upon receipt of your EOB. If you have questions about your bill or the email you will receive in advance of us debiting your card, please call (402) 302-2273.