Office sign-in sheet



ADVANCED DERMATOLOGY ASSOCIATES

Medical, Cosmetic and Surgical Dermatology

□Midtown Manhattan □Bronx: Coop City □Bronx:Third Ave. □Bronx: ParkChester □Bronx: Fordham

200 Central Park S, 107 2100 Bartow Ave, 211 291 East 149 St. 1455 West Ave 2432 Grand Concourse 501 Btw 7th Ave & 59 St. Bay Plaza Btw. Cortland & Morris Next to Post Office Poe Building 212.262.2500 718.671.1000 718.742.1000 718.239.1500 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 Advanced Dermatology of New York, P.C 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, Advanced Dermatology of New York, P.C 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 Advanced Dermatology of New York, P.C , 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 (if different from above): ______________________________________

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Billing Zip Code: ____________________

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