Credit Card on File Policy

It is AFC policy that we require a Credit or Debit card on File for any future balances your insurance may place into your responsibility from today’s visit. This process is rapidly being adopted in the healthcare industry and is to ensure smooth transactions and efficient billing practices.

AFC does not retain your actual Credit Card information on File. We use a Compliant Credit Card Merchant Services Processor who provides our system with an Encrypted Token or Reference to your card. Only the last 4 Digits of your card will appear in our system, we only have visibility to the encrypted token and have obtained authorization via this agreement from you.

After today’s visit, we will submit a claim to your insurance carrier. Once your insurance carrier has processed the claim, they will provide you with an Explanation of Benefits (EOB); your insurance carrier will then notify us of the payment amount for which you are responsible. We will attempt to charge your Credit Card on File for the amount your insurance would like us to collect. Charges will be for the exact amount due unless the amount is over $1,000 in which case you may need to call to make an additional payment.

Please provide the front desk staff with your Photo ID, insurance card, and preferred method of payment. You will be notified on at least ten (10) Calendar days via e-mail and/or text before your credit card on file is charged (if applicable) should you acquire an Open Balance. If you have any questions or concerns regarding the open balance or to change payment methods, please contact the AFC Denver Billing Department at 303-782-1111.

I, the undersigned, authorize and request that my Card is saved on file and to charge my credit/debit card for balances due for this date and or future dates of service for services rendered that my insurance company identifies as my financial responsibility. This authorization relates to all balances for services provided to me by AFC and will remain in effect until my account is paid in full.