Informed Consent for use of Ivy Pay Services and Payment Authorization
UPON CREATING AN IVY PAY CARD PROFILE YOU CONSENT AND AUTHORIZE YOUR PROVIDER TO USE YOUR IVY PAY CARD PROFILE TO CHARGE YOUR CARD, WHETHER THAT BE A CREDIT, DEBIT, HSA OR FSA CARD, THE COST OF PROVIDER’S SERVICES FOR PAYMENT OF PROVIDED SERVICES AS REQUIRED BY PROVIDER PRACTICE POLICIES. PLEASE NOTE: WE DO NOT STIPULATE THE FEE FOR PROVIDER’S SERVICES. PROVIDER PRACTICE POLICIES OUTLINE THE AGREED AMOUNTS. YOUR PROVIDER’S PRACTICE POLICIES ARE THEREBY INCORPORATED BY REFERENCE AND ATTACHED TO THESE PAYOR TERMS.
UPON CREATING AN IVY PAY CARD PROFILE YOU FURTHER UNDERSTAND THAT THIS AUTHORIZATION OF YOUR PROVIDER TO CHARGE YOUR IVY PAY CARD PROFILE WILL REMAIN IN EFFECT UNTIL YOU CANCEL YOUR IVY PAY CARD PROFILE AND YOU FURTHER AGREE TO NOTIFY YOUR PROVIDER OF SUCH CANCELLATION BEFORE YOUR NEXT SCHEDULED DATE OF PROVIDER’S SERVICES.
UPON CREATING AN IVY PAY CARD PROFILE YOU CONSENT TO HAVE YOUR CARD KEPT ON FILE WITH THE IVY PAY SERVICE AS AN ELIGIBLE PAYMENT METHOD WE HAVE ON RECORD FOR YOU.
UPON A CHARGE BY YOUR PROVIDER, YOU AGREE TO PAY THE CHARGED TOTAL AMOUNT ACCORDING TO CARD ISSUER AGREEMENT.
YOU CERTIFY THAT YOU ARE AN AUTHORIZED USER OF THE CARD YOU ADD TO YOUR ACTIVE IVY PAY PROFILE AND WILL NOT DISPUTE THE CHARGES MADE BY YOUR PROVIDER ACCORDING TO THESE PAYOR TERMS WITH YOUR BANK OR CREDIT CARD COMPANY, SO LONG AS THE TRANSACTIONS CORRESPOND TO THESE PAYOR TERMS TO WHICH YOU CONSENT AND UNDERSTAND YOU HAVE AUTHORIZED BY CREATING AN IVY PAY CARD PROFILE.
YOU UNDERSTAND THAT YOUR PROVIDER DOES NOT NEED ANY ADDITIONAL CONSENT BY YOU, THE USER, WHETHER YOU ARE THE USER OF THE PROVIDER’S SERVICES OR THE RESPONSIBLE PAYOR TO THE USER OF THE PROVIDER’S SERVICE, TO MAKE A CHARGE OR REFUND A CHARGE TO YOUR ACTIVE IVY PAY CARD PROFILE. FOR PURPOSE OF CLARITY, YOU AGREE THAT NO PRIOR-NOTIFICATION OF CHARGES WILL BE PROVIDED.
YOU UNDERSTAND THAT IF YOUR PROVIDER’S PRACTICE POLICIES INCLUDES LATE CANCELLATION FEES OR NO-SHOW FEES THAT YOUR PROVIDER DOES NOT REQUIRE ANY ADDITIONAL CONSENT BY YOU, THE USER, TO MAKE A CHARGE TO YOUR ACTIVE IVY PAY CARD PROFILE.
UNLESS YOU NOTIFY US BEFORE A CHARGE THAT YOU WANT TO CANCEL, YOU UNDERSTAND AND AUTHORIZE YOUR PROVIDER TO MAKE CHARGES AND US (WITHOUT NOTICE TO YOU, UNLESS REQUIRED BY APPLICABLE LAW) TO COLLECT THE THEN-APPLICABLE FEE, PER YOUR PROVIDER’S REQUEST AND ANY TAXES, USING YOUR ACTIVE IVY PAY CARD PROFILE, OR ANY ELIGIBLE PAYMENT METHOD WE HAVE ON RECORD FOR YOU.
YOU UNDERSTAND THAT YOUR CREATION OF AN IVY PAY CARD PROFILE INDICATES THAT YOU ARE AWARE THAT YOU WILL RECEIVE TEXT MESSAGES FROM THE IVY PAY SERVICE AND YOU CONSENT TO RECEIVING TEXT MESSAGE FROM THE IVY PAY SERVICE. YOU UNDERSTAND THAT IN ORDER TO FACILITATE YOUR ACTIVE IVY PAY PROFILE, IVY SENDS YOU TEXT MESSAGES SUCH AS CHARGE CONFIRMATION, REFUND CONFIRMATION, REMINDERS TO ADD CARD OR UDPATE CARD AND OTHER NECESSARY TEXT MESSAGES IN ORDER TO PERFORM THE IVY PAY SERVICES. TO MAINTAIN HIPAA COMPLIANCE, NO PHI WILL BE TRANSMITTED IN TEXT MESSAGES SENT TO YOU BY IVY PAY SERVICES. YOU UNDERSTAND THAT TEXT AND EMAIL ARE UNSECURED MEANS OF COMMUNICATIONS, AND HAVE BEEN INFORMED THAT ANY OF YOUR REPLIES TO TEXT MESSAGES OR EMAIL MESSAGES FROM THE IVY PAY SERVICE THAT CONTAIN PATIENT HEALTH INFORMATION PROVIDED BY YOU CANNOT BE SECURED BY YOUR PROVIDER OR US. YOU UNDERSTAND THAT TEXT MESSAGES YOU RECEIVE FROM IVY PAY SERVICE MAY NOT BE FREE, DEPENDING ON THE PLAN YOU HAVE IN PLACE WITH YOUR CELL PHONE COMPANY. YOU UNDERSTAND THAT YOU, NOT YOUR PROVIDER, NOT US, ARE SOLELY RESPONSIBLE FOR ANY FEES ASSOCIATED WITH RECEIVING TEXT MESSAGES.
