Credit Card on File Acceptance Form

At Hallett Physical Therapy we are committed to making our payment  processes as simple and efficient as possible. To streamline our billing and payment system and to provide a seamless, convenient way for patients to pay their bills, effective April 1 2019, Hallett Physical Therapy will require all patients keep an active credit card on file with us. We will only charge your credit card if  you  have a balance with us that you have not  fulfilled  at the time of service.  Other circumstances when your card will be charged are limited to missed or canceled sessions without 24 hours notice, or equipment fees that are discussed at time of purchase.  

 

I allow Hallett Physical Therapy to  charge my credit card for any outstanding balances. This may include: missed/canceled appointments without 24-hour notice, unpaid visits or equipment.  Missed or canceled appointments without 24-hour notice will be charged $80 at the time of the appointment.

 

If the credit card that I give today changes, expires, or is denied for any reason,  I agree to immediately give Hallett Physical Therapy a new, valid credit card which I allow them to key-in over the phone. Even though Hallett Physical Therapy isn’t swiping this card in person, I agree that the new card will be subject to the financial policy listed here and may be used with the same authorization as the original care which I presented in person.

 

I understand this form is valid until I cancel this authorization through written notice to Hallett Physical Therapy.

Hallet Physical Therapy – Credit Card on File 

Thank you!