DERMRIGHT PATIENT PAYMENT AUTHORIZATION

As part of our commitment to providing seamless care while also supporting environmental sustainability, we now require a credit card on file to cover copay, coinsurance and deductible payments. This change is designed to improve efficiency, enhance security, and reduce paper waste. 

By securely storing your payment information, we can:

• Simplify your billing process, making it easier and faster for you to pay any remaining balances.

• Eliminate the need for paper statements, supporting a greener environment by reducing paper usage.

• Ensure timely payments without the hassle of writing and mailing checks.

Your information will be stored securely and will only be charged for copay, coinsurance or deductible amounts determined by your

insurance after your claim has been processed. This system helps us provide more efficient care while doing our part to protect the environment. If an amount is charged in error, a refund will be provided as necessary.

Thank you for your understanding and helping us create a more sustainable future! 

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PATIENT INFORMATION

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CREDIT CARD AUTHORIZATION

DermRight LLC is authorized to charge the credit card on file for any outstanding balances related to medical services rendered to the patient, listed above, including but not limited to co-pays, co-insurance, and deductibles as determined by the patient's insurance provider.

I understand that:

NOTE: Card Information (Securely stored & processed in compliance with PCI standards).

Card Type:

Cardholder Name:

Card Number:

Security Code / CVV:

location example here

Expiration Date:

Billing Zip code:

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ACKNOWLEDGEMENT & SIGNATURE