Storybook Pediatrics requires a credit, debit, or health savings card on file. Providing quality healthcare to our patients and good service to their parents is very costly. Adequate cash flow is critical to the financial viability of this practice; therefore, parents must provide a concrete guarantee of payment for services. I agree to place a credit, debit, or Health Savings Account card on file in my guarantor record. I understand that only the last four numbers of the card are visible to any employees who might have access to my guarantor record. I understand that after the processing of insurance claims is complete that I will be billed via email for any remaining amounts that are deemed patient responsibility and that the balance is due within 14 days of billing. Should payment not be received by this office within the 14 days subsequent to billing, I understand that the credit/debit card placed on file will be run to pay the balance. I understand that should the amount of the balance be problematic to pay within the 14 day window that it will be my responsibility to call the billing office and arrange a payment plan. I understand that MY CARD WILL NEVER BE CHARGED UNLESS I FAIL TO PAY MY ACCOUNT BALANCE WITHIN THE TIME LIMIT STATED ABOVE.