Triangle Family Dentistry

CREDIT CARD ON FILE AGREEMENT

Triangle Family Dentistry is implementing a new credit card on file policy effective February 2023. Like many other dental and medical practices, we have adopted a similar policy. We kindly request our patient’s guardian/guarantor provide a credit card which will be used to pay a balance. Co-pays are still due at the time of service. Your credit card information will be obtained and kept securely on file.
 
After your claim is paid, we will process your card on file for any balances less than $100.00 and send you a receipt for the charge. For balances over $100.00, you will receive an electronic statement, and your prompt payment is expected within 7 days. You may call our office if you have questions about your balance.
 
This “Card-on-File” policy simplifies payment for you, and it reduces paperwork, ultimately helping lower the cost of care. Our Guest Support team is always available to answer questions about the Credit Card on File payment method or any balances due.


* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
 
 
By signing below, I authorize Triangle Family Dentistry to keep my signature and my credit card information securely on-file in my account. I authorize Triangle Family Dentistry to charge my credit card for any outstanding balances equal to or less than $100.00.
Appointment Location? *
Credit Card Type:
*Please be advised, if the credit card on file differs from the CC info provided above, we will use CC on file.*
Please list any person(s) you authorize this credit card for:
Credit Card Holder’s Signature: *
clear
 +

Frequently Asked Questions About the CC on File Agreement

How much and when will the money be taken from my account?

On average, insurance companies take approximately 30-45 days to process submitted claims. Whatever the allowed amount is, your copay, coinsurance, and deductible are taken into consideration. It simply depends on your individual policy and what you may owe. Once the insurance explanation of benefits is received and posted to your account, your card will only be charged up to $100.00. If your balance is greater than $100.00, you will receive an electronic statement.
 
How do you safeguard the credit information you keep on file?
We use the same methods to guard your credit card information as we do for your medical information. The card information is securely protected by the credit card processing component of our HIPAA-compliant practice management system. This system stores the card information for future transactions using the same technology that any online retailer would. We cannot see the card number - only the last four numbers, giving us no way to use the card outside of the billing system. There is no way to export the card information out of our system. The only way to use it is to process a payment in our practice management system.
 
What are the benefits?
It saves you time and eliminates the need to write checks, buy stamps, or worry about delays in the mail. It also allows us the chance to refund patients easily. Finally, it cuts down on germs while handling cards to pay for bills; there is no need to take your card out if it is on file. It also drives our administrative costs down because our team sends out fewer statements and spends less time taking credit card information over the phone or entering it from the billing slips sent in the mail, which are less secure methods than us storing the information. The extra time the team has can now be spent directly helping the patients, either over the phone, or with insurance claims, or over the phone.
 
I always pay my bills on time. Why do I have to do this?
Reducing unnecessary costs is essential for us to continue as an in-network provider with most insurance companies. It also allows us the chance to help our patients avoid the additional costs and hassle of dealing with the collection department. This does not affect your insurance coverage.
 
What if there is a payment discrepancy or I have other payment questions?
Please contact your Triangle Family Dentistry location. This policy in no way compromises your ability to dispute a charge or question your insurance company’s explanation of benefits.