By signing below, I agree to all of J Shoshana & Associate’s Credit Card on File Policy. Additionally, I authorize J Shoshana & Associates to keep my signature and a valid credit/debit card number securely on-file in my account.

I allow J Shoshana & Associates to automatically charge my credit card for any outstanding balances over 30 days past due. These may include:

  • Insurance denials for ANY reason (including no referral on file).
  • Missed or cancelled appointments.
  • Deductibles.
  • Co-insurances.
  • Partially paid claims.

If the credit card that I give today changes, expires, or is denied for any reason, then I agree to immediately give J Shoshana & Associates a new, valid credit card which I will allow them to key-in over the phone. Even though J Shoshana & Associates is not swiping this card in person, I agree that the new card will still be subject to the financial policy listed here and may be used with the same authorization as the original card which I presented in person.

I understand that I am responsible for payment for all medical services provided to me by J Shoshana & Associates.

I understand that my insurance may deny or delay payment for these services or only partially pay them. As such, I agree to allow J Shoshana & Associates to immediately charge my credit card on file for the balance if that happens.

I understand that this form is valid until I cancel this authorization through written notice to J Shoshana & Associates.

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