Greenlight Authorization Form for Surgical Procedures
HWHC collects a pre-surgical deposit of $300.00 from all patients prior to any surgical procedure(s). You may still have a balance due once your claim has processed with your insurance payer. To provide a convenient way for you to pay your portion of the care provided, we will set a greenlight payment agreement with you to charge your card or bank account once your insurance payer has processed your claim. EACH VISIT WILL HAVE A SEPARATE AGREEMENT. Your card or bank account will not be randomly charged for any balances you have not authorized.
In order to maintain a cost effective manner for all our patient balances, we ask that you adhere to HWHC’s financial policy. By signing below, you are agreeing to its terms:
1. I understand that my signature and payment information will be maintained on file for future use by the practice. The applicable payment card or bank account number will be truncated and “tokenized” in order to help maintain the security of my payment information.
2. I authorize HWHC to apply charges to my payment card and/or bank account for all amounts owed to the practice now or at a future date for surgical procedures for amounts due after insurance has processed your claim.
Please note, once your insurance payer has processed your claim and your balance comes due, you will receive an e-mail notification that your card will be charged in two days with the amount your insurance company indicates you owe.
If the amount you owe is less than what you authorized, we will charge the lesser amount.
If the amount due is more, we will only charge up to what you authorized and balance bill you for the remainder of the balance.
3. I authorize HWHC to send electronic account statements and invoices to my email address on file. I understand that I may not receive a copy of any such invoice via U.S. Mail. I understand that it is my responsibility to maintain a current email address on file with the practice at all times.
4. This authorization will remain in effect until I provide written notice of cancellation to the practice. I understand that I can cancel the authorization only for future services. Authorization for services already rendered cannot be cancelled or refunded.
I am authorizing HWHC to charge my card and/or bank account the following amount once the insurance payer has processed my
I agree to notify HWHC, in writing, of any changes in my payment or other information.
(Typing your name here will be counted as a E-Signature)
By clicking Submit you agree the above information is correct and agree that all signatures are E-Signatures.