As you know if you have ever checked into a hotel or gone to a dentist, the first thing you are asked for is a credit/debit card, which is imprinted and later used to pay your bill. This is an advantage for both you and the hotel or dentist since it makes checkout easier, faster, and more efficient. At that time, any remaining balance owed by you will be charged to your credit card. A copy of the charge will be mailed to you, upon request.

Due to patient demand, we have implemented a similar policy. You will be asked for a credit/debit card number at the time you check in and the information will be held securely until your insurances have paid their portion and notified us of the amount of your share. At that time, any remaining balance owed by you will be charged to your credit card, and a copy of the charge will be mailed to you upon your request. This new process will be an advantage to you, since you will no longer have to write out and mail us checks. It will be an advantage to us as well, since it will greatly decrease our billing costs. The combination will benefit everybody in helping to keep the cost of healthcare down.

We require that you provide this information before your visit with the provider, so your cooperation in completing the form prior to arrival is appreciated. This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment. We will charge you only the portion of the insurer-determined payment apportioned to you, the patient. Co-pays are still due at the time of the visit. This policy does not apply if you are a cash-paying patient. You will continue with the same policy that we have in place now and will pay at the time of each service.

Credit/Debit Card Consent Form

Westminster Medical Clinic: 303-487-5165
Westmed Family Healthcare: 303-450-4680