EZ Pay Payment Feature

EZ Pay Payment Feature

"EZ Pay" is an electronic payment feature of the OHS Gateway designed specifically for medical practices supporting both checks and credit cards. A patient makes a co-payment either by check or credit card and signs an authorization allowing the practice to charge that same card or checking account in the event the insurance payment is insufficient to cover the cost of the visit. It is basically a future authorization allowing the practice to charge the card or check after the insurance company submits payment to the provider.

EZ Pay Authorization

Patient Name:

Patient Acct Number:

Patient Address:

Patient City, State, Zip

Payment Type:
ACH CREDIT

Amount Authorized:

I hereby authorize this office to keep this signature on file and to charge my credit card or checking account for the balance of charges not paid by my insurance within 90 days, not to exceed the amount shown above for this visit only.

I hereby assign my insurance benefits to the provider listed above. I understand this form is valid for one year unless I cancel the authorization through written notice to the health care provider.

______________________ Date: __________
Signature

Download EZ Pay Form