By signing this form, I, the undersigned patient or authorized cardholder, hereby authorize Curaechoice Inc. (“Curaechoice”) to securely store and charge listed payment methods for amounts due in connection with healthcare services rendered to the above-named patient and family members covered under their health plan.

1. High-Deductible Health Plan (HDHP) with a Health Savings Account (HSA): I am enrolled in a health insurance plan defined as an HDHP with an HSA. I acknowledge that under the terms of such plan, I am personally responsible for payment of all medical costs up to the deductible amount, as well as any applicable co-insurance, co-payments, or services not covered by my health plan.
2. Health Savings Account and secondary form of payment: I acknowledge that it is my responsibility to ensure my HSA is pre-funded each plan year up to fifty percent of the annual minimum deductible amount set by the IRS. I understand I am required to provide an HSA debit card for qualified medical expenses and keep an active credit card on file with Curaechoice. I authorize Curaechoice to directly withdraw payment from my HSA or credit card for amounts owed to Curaechoice. If Curaechoice is unable to collect required payments, my access to the Curaechoice program may be suspended until payment is received.
3. Use of Card: I authorize Curaechoice to charge my credit card for balances that are my responsibility after claims have been processed, including but not limited to: deductible payments, co-insurance amounts, co-pays, non-covered services. Deductible amounts due will not be collected at the time of service at the provider location; Curaechoice will bill the member directly once claims are processed.
4. Authorization for Recurring Charges: I understand that this authorization permits Curaechoice to initiate recurring transactions on my card as necessary to satisfy outstanding balances. A receipt for each payment will be provided upon request, and all charges will be reflected in my statement of account.
5. Security and Privacy:I understand my credit card information will be securely stored in compliance with applicable data security standards (e.g., PCI DSS) and used solely for authorized billing purposes. Only authorized personnel or secure third-party processors will have access according to all applicable data security and privacy standards.
6. Revocation of Authorization: I may revoke this authorization at any time by providing written notice to Curaechoice by contacting support@curaechoice.com. I understand that revocation does not affect any charges made prior to the date of revocation.
7. HIPAA Disclosure: I understand Curaechoice may use and disclose limited health and billing information to process payments, in accordance with HIPAA regulations. Any third-party billing partners will be contractually obligated to maintain privacy and data security.
8. Disputes and Inquiries: I agree to notify Curaechoice of any disputes related to billing within 30 days of the charge date. I understand that any chargebacks or payment reversals may be subject to a service fee.
9. Voluntary Consent: I acknowledge that I am voluntarily signing this authorization. This form is not a condition of treatment, except where permitted by law for cost-sharing amounts under my plan.