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Credit Card on File Agreement .pdf


Original filename: Credit Card on File Agreement.pdf
Title: Virginia Cancer Care, Inc
Author: dee

This PDF 1.7 document has been generated by Microsoft® Word 2016, and has been sent on pdf-archive.com on 01/06/2017 at 03:43, from IP address 70.106.x.x. The current document download page has been viewed 201 times.
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Virginia Cancer Care
19415 Deerfield Avenue

1860 Town Center Drive
Suite 260
Reston, VA 20190
Phone 703-794-4400
Fax 703-729-1446

Suite 107
Leesburg, VA 20176
Phone 703-729-6030
Fax 703-729-1446

Credit Card on File Agreement
We have implemented a new policy, which enables you to maintain your credit card
information on file in our office. This information will be securely held until your
insurance provider has paid their portion of your bill and notified us of the amount
that is your responsibility. At that time, any balance, which you owe to our office for
medical services that have already been preformed, will be charged to your credit
card. We also will mail you a copy of what charges were paid along with a receipt.
This in no way compromises your ability to dispute a charge or question your
insurance company’s determination of payment.
Co-pays are still due at the time of service.

I authorize VIRGINIA CANCER CARE to charge any outstanding balances on my
account, including co-pays, coinsurance, fees for late cancellation of appointments
and no show fees to the following credit card:

Please circle one:

Visa

MasterCard

Name on Card:__________________________________________
Account Number:________________________________________
Expiration Date:_________________________________________
3 Digit Security Code: (On Back of Card)__________________________________
Signature:______________________________________________
Date:___________________________________________________
Updated 5/25/2017


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