Office sign-in sheet



Medical, Cosmetic and Surgical Dermatology

□Midtown Manhattan □ Harlem □Bronx: Coop City □Bronx:149th st □Bronx:ParkChester □Bronx: Fordham

200 Central Park South 1-3 West 125th St 2100 Bartow Ave 291 East 149th St 1455 West Ave 2432 Grand Concourse Ave

Suite 107 New York, NY 10027 Suite 211 Bronx, NY 10451 Bronx, NY 10462 Suite 501

New York, NY 10019 212-246-6800 Bronx, NY 10475 718-742-1000 718-239-1500 Bronx, NY 10458

212-262-2500 718-671-1000 718-537-5000

Patient Credit Card on File Agreement

We have implemented a policy which enables you to maintain your credit card information securely on file within eClinicalWorks. In providing us with your credit card information, you are giving CITY DERM permission to automatically charge your credit card on file for your co-pay [or any other patient(s) you have listed on this form] at time of service. By signing this you authorize this agreement will remain in effect until the expiration of the credit card account and that you may revoke this form at any time by submitting a written request.

Co-pays: Co-pays are due at time of the office visit.

Outstanding Balance: If your insurance provider has paid their portion of your bill [or any other patient(s) you have listed on this form] and there is an outstanding balance owed, CITY DERM will notify you via phone and/or email. If by the final billing notice, we do not receive a response from you or your payment in full, at that time, any balance owed will be charged to your credit card. A copy of the charge will be sent by email or mailed to you. This in no way compromises your ability to dispute a charge or question your insurance company’s determination of payment.

I authorize CITY DERM , to charge co-pays and outstanding balances on my account to the following credit card:

Patient's Signature: ____________________________________ Date _____________

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Visa Mastercard American Express Discover

Credit Card Holder's Name: ______________________________________

(Please Print)

Patient's Full Name[?]

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h1Ž (if different from above): ______________________________________

(Please Print)

Billing Zip Code: ____________________

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