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General Financial Policy, CC Authorization, Consent to

General Financial Policy, CC Authorization, Consent to 2026

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The document outlines the financial policy and patient consent requirements for Spine & Joint Physicians of Frisco. It specifies that patients must pay their financial responsibilities at the time of service, including co-pays and deductibles. Patients are responsible for understanding their insurance coverage and obtaining necessary referrals from their primary care physician. It also details payment terms for post-visit balances, no-show fees, and authorization for care, while acknowledging the HIPAA notice of privacy practices.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information at the top of the form, including your name and contact details. This ensures that all communications regarding your financial policy are directed to you.
Review the Financial Policy section carefully. Acknowledge your understanding of payment responsibilities by checking the appropriate box or signing where indicated.
In the Insurance Coverage section, provide details about your insurance provider. If applicable, include any necessary policy numbers and ensure that you understand your coverage limits.
For the Managed Care Referral Process, indicate whether a referral is required for specialist visits. If so, confirm that you will obtain this from your primary care physician before scheduling an appointment.
Fill out the Payment of Post Visit Balances section by agreeing to pay any outstanding balances within 30 days of receiving a statement.
Acknowledge the No Show and Cancellation Policy by signing in agreement. This confirms your understanding of potential fees associated with missed appointments.
Finally, complete the Authorization of Care section by signing and dating it. If applicable, have a legal representative sign on behalf of a minor or incapacitated patient.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Is a credit card authorization the same as a charge?

When you place an order with us, we initially authorize your credit card. This means we verify that the funds are available, but we dont actually charge your card at this stage. You might notice an authorization hold or a pending charge on your statement.

What is a CC authorization?

A credit card authorization form is a document that customers (or cardholders) fill out to grant businesses the permission to charge their credit card. Credit card authorization forms are more often used for larger purchases (think cars, computers, etc.) than they are for smaller, everyday items.

Who can access my financial records?

Without your consent, a Federal agency that wants to see your financial records may do so ordinarily only by means of a lawful subpoena, summons, formal written request,or search warrant for that purpose.

Is a credit card authorization form legal?

Credit card authorization forms are a best practice for merchants. While its not legally required, It is highly recommended to ensure both you and your client are aware of how charges will be processed for future transactions.

Is it safe to give a credit card authorization form?

The payment information recorded on an authorization form is sensitive and must be handled in a PCI-compliant manner to prevent cardholder details from being stolen.

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At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.

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How do you write an authorization for a credit card?

Typically it contains: The cardholders credit card information: Card type, Name on card, Card number, Expiration date. The merchants business information. Cardholders billing address. Language authorizing the merchant to charge the customers card on file. Name and signature of the cardholder. Date.

What is the meaning of CC authorization?

Card authorization means the payment is approved by the issuer; its from an active account with sufficient funds.

Can I cancel a credit card authorization?

Locate the issuing banks contact number (printed on the back of the cardholders credit card). Contact the issuing bank and provide the authorization code(s) for the transaction. Request that the bank reverse the authorization.

General Financial Policy, CC Authorization, Consent to 2026

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