Credit Card On File Patient Agreement
  • By signing below, I agree to Lifestyle Medical Center’s Credit Card on File Policy (“CCOF”) and I authorize Lifestyle Medical Centers (“LMC”) to keep my signature and a valid credit/debit card number securely on-file in my account. I allow LMC to automatically charge my credit card for any outstanding balances, which will include, but is not limited to: insurance denials, deductibles, co-insurances, and partially paid claims.

    If the credit card that I give today changes, expires, or is denied for any reason, then I agree to immediately give LMC a new, valid credit card which I will allow them to key-in over the phone. Even though LMC is not swiping this card in person, I agree that the new card will still be subject to the financial policy listed here and may be used with the same authorization as the original card which I presented in person.

    I understand that I am responsible for payment for all services provided to me by LMC. I understand that my insurance may deny or delay payment for these services or only partially pay them, and I agree to allow LMC to immediately charge my credit card on file for the balance if that happens. I understand that this form is valid until I cancel this authorization through written notice to LMC.

    Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.
  • Credit Card Information

  • Protected in vault Data collected via fields that have our security seal are encrypted and stored with the highest global security standard — PCI compliance. Your data is absolutely safe in Vault.
  • I, authorize Lifestyle Medical Centers and its affiliates, to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transaction on my account.
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