Until further notice, I authorize Alan E. Oshinsky, M.D., P.A. to charge the patient-responsible balance(s) to my credit/debit card on file.
This card will also be used for any missed appointment fees charged to your account. You may revoke this authorization at any time.
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I understand that once insurance has processed the claim for my services and paid their portion, I will receive an Explanation of Benefits (EOB) from the insurance company.
The EOB will state any balance remaining that I am responsible to pay. I agree that Alan E. Oshinsky, M.D., P.A. may charge my credit/debit card on file for the balance due when they receive the Explanation of Benefits.