Printing a Payment Plan Consent Form

The Payment Plan Consent form is accessed from the Credit Card Payment Plan window and authorizes your office to keep a patient’s signature on file and charge his credit card on a recurring basis.

The consent form is generated in two ways:

The software prompts you to print a consent form immediately after you create or edit a payment plan. You must print the form before you can continue. If you have edited a payment plan, a modified version of the form is printed, including a new payment schedule.

You can print the consent form at any time once a payment plan is created.

The payment plan consent form is archived whenever it is printed and is displayed in the document tree for the patient or account. The document is labeled as Payment Plan Consent Form. If the consent form was printed because a user edited the payments, the text reads Payment Plan Consent Form (Modified).

To print an existing consent form:

In the Account List or Patient List window, select a record and click Credit Card Payment Plan. The Credit Card Payment Plan window is displayed.
Click Consent Form. The Output Options—Payment Plan Consent Form window is displayed.
Select the output option and click OK.

Two copies of the consent form—an Office Copy and a Cardholder Copy—are printed.

The consent form will not print if a payment plan is not set up.

Additional information:Additional information:

The consent form lists the Monthly Payment, Last Payment, Start Date, Number of Payments, Financed Amount, and Down Payment.

Each payment is displayed on a separate line.
Payments are sorted in ascending order.
The date to be authorized (or date authorized) and the amount are displayed for each payment.
If a payment has already been authorized, the text (Completed) is displayed after the payment.
If a payment has been voided, the text (Voided) is displayed after the payment. The payment amount is $0.00.
If a payment has failed authorization, the text (Failed) is displayed after the payment. The payment amount is the amount for which the payment failed to be authorized.

If the form is being reprinted because the payment plan terms have been modified:

The title reads PAYMENT PLAN CONSENT FORM (MODIFIED).
The text $XX.XX per payment on a monthly basis is replaced with unequal monthly payments.
The note This is a modification from the original payment plan terms created on mm/dd/yy is displayed.
Payment Schedule is changed to New Payment Schedule.