I authorize The Johns Hopkins Medical Institutions and affiliated providers to charge my credit card in event of the following:

• If an open balance exists on my account after final charges have been posted for medical services provided. (This may occur because all up-front payments collected are based on estimates only, which may vary from actual final charges.)
• Failure to appear for an appointment without giving proper notice of cancellation at least 2 business days before the scheduled appointment. This cancellation fee is US$250 per appointment.
• Failure to appear for an Executive Health appointment without giving proper notice of cancellation at least 10 business days before the scheduled appointment. This cancellation fee is US$400.

As the amount previously collected is based on an estimated amount, there is a possibility a balance could exist at the time of the final billing. In that instance, the Finance Department will attempt to contact the patient prior to charging the credit card on file for any outstanding balance via telephone or e-mail. If other payment arrangements need to be made, available options can be discussed at that time. In the event the Finance office is unable to reach the patient, the credit card will be charged in accordance to the signed credit card authorization form on file, and a statement will be forwarded to the patient via FedEx.

I acknowledge any deposit I make is based on Cost Estimate ONLY, and Actual Charges may vary from the Cost Estimate. I acknowledge responsibility for any balance due between the Cost Estimate and the Actual Charges.