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Credit Card Authorization

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It is recommended you print or save this Authorization for future reference.

Updated October 10, 2022

By selecting the “I AUTHORIZE CHARGING OF MY CREDIT CARD(S) INFORMATION ON FILE” button, you agree to the following:

  1. In many cases, the credit card used to schedule appointment(s) through Peak Health and Performance’s scheduling website remains on file per the Acuity Scheduling and the pay processors’ terms and conditions. You may add a new credit card to your file for future usage by entering that credit card information during the next self-scheduling or self-payment of an appointment and clicking “save for future payments”.
  2. Cash Pay clients can complete payment of any unpaid patient fees themselves by referring to an applicable appointment confirmation or reminder email from Peak Health and Performance, and selecting the Pay button which will direct them to the payment processing section of Peak Health and Performance’s scheduling website for that appointment.
  3. You authorize the staff at Peak Health and Performance to charge your credit card on file for any and all unpaid patient fees resulting from:
    • Completed appointment(s) of yours (or of a child whom you are the parent or guardian), including any and all unpaid fees deemed patient liability by the HMO following the finalization of a submitted claim to the HMO of such appointment(s), and
    • Any and all fees which result from a late appointment cancellation you make (or your representative makes) or when you fail (or your child fails) to show up for a scheduled appointment. Late cancellation/no-show fees and definitions are specified in the Peak Health and Performance’s Physical Therapy Consent to Care (Cancel / No Show / Late Policy section).
  4. In the event of multiple unsuccessful attempts to charge your credit card, we will contact you to resolve your credit card arrangements and coordinate your payment. Unpaid patient fees which are overdue by more than 60 days may restrict your ability to schedule future appointments, and may prompt Peak Health and Performance to take additional actions to recoup those unpaid patient fees. Additional information is in Peak Health and Performance’s Physical Therapy Consent to Care (Financial section).