We do not us PM. We considered doing CCOF in our office but, we didnt. We do it on a case by case basis. Below is our form for Credit Card Payments taken over the phone. I have used this before for patients that did want us to keep their credit card on file and take out 1 payment for several months in a row. I had them answer the questions and then sign the bottom. The form was then scanned into their chart and I kept a special EXCEL spread sheet with the information and contract. This has worked out well. I did tell the patients that if for any reason the card was declined I would call them and make other arrangements. That only happened once and the patient was very grateful and paid her balance off earlier than planned.
CREDIT CARD OVER THE PHONE PAYMENT FORM
PATIENT ID:
NAME AS IT IS ON CC:
TYPE OF CC:
CREDIT CARD #:
EXP. DATE:
PAYMENT AMOUNT:
CALLER:
TAKEN BY:
DATE:
PROCESSED DATE & TIME:
PROCESSED BY:
Does patient want a copy of the receipt sent to them by the Portal?
Does patient want to set up monthly payment plan?
What date in the month does payment need to come out?
From to Healthy Concepts will charge the CC above the amount of $ at the above designated time of the month for the months of .
Patient Signature: Date:
Employee Signature:
Allison
