Scheduled Payment Will Make Your Life Easier

1. 1. It’s convenient (saving you time and postage)
2. 2. It’s worry free. Your payment is always on time (even if you’re out of town), eliminating late charges and the possibility of collection agency reporting

Here’s How Scheduled Payment Works:

You authorize Avance Care, P.A. to charge your credit card for the balance owed by you for your visits after the claims have been created (for self-pay patients) or processed through your insurance provider. The signature below will authorize Avance Care to charge your credit card for any fees not collected at the time of service or not covered by insurance and/or deductible, co-pay, and co-insurance portions of your medical services provided. A receipt for the charge will be emailed to you to the email address you provide on this authorization.

1. 1. The authorization you are signing will be valid for one year from date of submittal or you cancel the authorization or the card on file expires within the year.
2. 2. All patients will require a separate form to be filled out.
3. 3. Your credit card will only be charged after 30 days from the initial statement mailing alerting you of your balance with us.
4. 4. Your credit card will not be charged if payment is made within 30 days of mailing the initial statement.

For the safety of your credit card information, Avance Care, P.A. has partnered with the industry leading PCI compliant payment gateway service, PayPal. The authorization is processed through a secured, encrypted channel and securely stored on PayPal's system using advanced tokenization security. Avance Care, P.A. does not store your credit card information on its electronic systems.

Please do not use any special characters on this form, including quotes or apostrophe.

I hereby authorize Avance Care, P.A. to charge the indicated credit card for cost of medical services received at Avance Care, P.A. locations. If I have insurance that Avance Care, P.A. is in-network, I authorize Avance Care to charge my credit card for deductible, co-pay, and co-insurance amounts as described above and any non-covered charges by my insurance provider. I certify that I am an authorized user of this credit card and will not dispute any charges with my credit card company without first making a good faith effort to remedy the situation directly with Avance Care, P.A. and as so long as the transaction corresponds to the terms indicated in this authorization form.