Credit Card Authorization Form for NEMT: Card on File, Deposits, and Cancellation Fees

A card on file makes private-pay rides simple for everyone. The family does not have to call after every dialysis run, and you get paid the day the ride ends. It only holds up if the cardholder agreed, in writing and in advance, to exactly what you charge. This form records that agreement, and it leaves off the two things that cause the most trouble later: the card’s security code and the rider’s health details.

How to use this template

1. Fill in Parts 1 and 4 before you hand it out. Put your prices in Part 4, or attach your rate sheet and write its date. Cross out any charge you do not use.
2. Give it to the person paying. For a parent’s rides, that is often an adult child, a guardian, or a facility’s business office. The rider does not sign unless the rider is the cardholder.
3. Keep it apart from your general terms. Visa’s rules require card-on-file terms to be shown separately from general purchase terms when the cardholder agrees to them.
4. Take the card in your processor, not on this form. Enter it in the processor’s secure storage while the cardholder is on the phone, or send the processor’s secure payment link. Write only the brand and last four digits in Part 5. If a card number arrives on paper, use the slip at the end and shred it once the card is entered.
5. Test the card before you keep it. Visa’s rules require an approval for the first charge, or for a zero-dollar account check when nothing is due yet, before a card is stored. If it is not approved, do not store the card.
6. Give the cardholder a copy. Regulation E requires one for debit cards and bank accounts charged on a schedule, and a copy settles most billing questions for any card.
7. Charge only what Part 4 allows. Send a receipt for every charge and record it in your payment log.
8. Start a new form when the deal changes. A different card, a different payer, or a new kind of charge needs a new signature. For new prices, give the notice Part 6 promises before they apply.

The template

Print it, or copy the fields into your booking system’s payment page. Circle or initial each choice that applies.

Part 1: Company being paid

Field	Entry
Company legal name, and the name riders know you by
Business address
Phone for billing questions
Email for billing questions
Website

Part 2: Rider

Field	Entry
Rider’s full name
Rider’s phone
Usual pickup address

Do not write diagnoses, the reason for visits, doctors’ names, insurance or Medicaid ID numbers, or medications on this form. Ride needs belong on the rider profile form, which stays with dispatch.

Part 3: Cardholder (the person paying)

Field	Entry
Cardholder’s full name, as it appears on the card
Relationship to the rider: self / family member / guardian or agent / facility / other
Billing address
Phone
Email for receipts and notices
Best way to reach you about charges: email / text / phone / mail

Part 4: What this card pays for

All amounts are in U.S. dollars.

Charge	Amount, or how it is figured	When it is charged	Cardholder’s initials
Each completed ride	Rates on the rate sheet dated ________	After each ride / weekly on ________ / monthly on ________
Standing rides	Days and times: ________	As chosen above
Deposit for a long or special trip	$________ or ______% of the written quote	When the trip is booked
Balance of a deposit trip	The written quote minus the deposit	After the ride
Late cancellation fee	$________ when cancelled less than ______ hours before pickup	After the missed pickup
No-show fee	$________ when the rider is not at the pickup after ______ minutes of waiting and ______ calls	After the missed pickup
Wait time	$________ per ______ minutes after the first ______ minutes	With the ride
Card surcharge, only where state law allows it	______% of each credit card charge, never on debit or prepaid cards	With each charge
Most we will charge at one time without asking you first	$________	Any single charge

Part 5: Card on file

Field	Entry
Card brand
Last four digits
Card type: credit / debit / HSA or FSA card
Name on the card

The full card number, expiration date, and security code are not written on this form. Our card processor keeps the card.

Part 6: Receipts, notices, refunds, and cancelling

Term	What we agree to
Receipts	A receipt for every charge, sent by ________ within ______ days
Changes to prices or these terms	We tell you by ________ at least ______ days before they apply
Debit card or bank account charged on a schedule	You have the right to notice of each amount and date at least 10 days before a charge that differs from the last one. Choose one: notice of every such charge / notice only when a charge is outside $______ to $______
Refund of a deposit	Full refund when the trip is cancelled at least ______ hours before pickup
Other refunds	________
If a charge is declined	We tell you in writing and give you at least 7 days to pay another way
Questions about a charge	Call or email us at the numbers in Part 1
How to cancel this authorization	Tell us by ________ at least ______ days before the next charge. Rides already given stay due.
When this authorization ends	On ________, or when you cancel it, whichever comes first

Part 7: Cardholder’s signature

I am the cardholder, or I am authorized to use this card. I authorize the company in Part 1 to charge the card in Part 5 for the charges I initialed in Part 4, on the terms in Part 6, until this authorization ends or I cancel it. I have received a copy of this form.

Field	Entry
Cardholder’s signature
Printed name
Date
Signed on paper / signed electronically

Part 8: Office use only

Field	Entry
Card stored in the processor on (date), by
First charge or account check approved (yes or no, date)
Copy given to the cardholder on (date), and how
Paper card slip shredded on (date), by
Authorization cancelled or ended on (date)

Card entry slip (only if a card number arrives on paper)

Cut this off. Enter the card in the processor, then shred the slip. Never write the security code.

Field	Entry
Card number
Expiration, month and year
Billing ZIP code
Entered by, and date
Shredded by, and date

What Visa requires before you keep a card on file

The Visa Core Rules and Visa Product and Service Rules (edition of April 18, 2026, section 5.8.11.1) say what a merchant must do before storing a card for later charges. The cardholder must give express informed consent to an agreement that holds each item below.

What Visa lists	Where it is on this form
A description of the service and the total price, or how the amount is figured	Part 4 and your rate sheet
Cancellation and refund policies	Part 6
Any surcharge, where surcharging is allowed	Part 4
Your location, address, email, and phone	Part 1
The card’s last four digits only	Part 5
How you will tell the cardholder about changes to the agreement	Part 6
The currency	Part 4
How the card will be used, and when and how often you charge it	Part 4
For charges with no set schedule, the event that sets off the charge	Part 4: a completed ride, a late cancellation, or a no-show
When the agreement ends, if it does	Part 6

The same section adds four duties, as of September 2026:

• Test before storing. After the agreement is signed and before the first charge, run an authorization for that charge, or an account verification if no payment is due yet. If it is not approved, do not store the card.
• Handle declines fairly. If a charge you start on a stored card is declined, notify the cardholder in writing and allow at least 7 calendar days to pay by other means.
• Keep the agreement. Keep it for as long as it lasts, and provide it to the cardholder or the card issuer on written request.
• Refund when you break the terms. Refund the full amount paid if you did not keep to the terms of the sale or service.

For charges on fixed dates, such as a weekly charge for standing dialysis rides, Visa also requires a simple way to cancel and the fixed dates or intervals in the agreement.

Why the form leaves off the security code and health details

The security code. The PCI Security Standards Council says card verification codes may not be kept after the charge they were collected for is authorized, even if encrypted, and that a customer’s permission does not change that (FAQ 1280, October 2023). A form with a box for the code turns every filing cabinet into a problem. Its guide for small merchants (version 2.0, August 2018) says the best protection is not to store card data at all, and suggests asking your processor about tokenization, which lets you charge the card again without holding the number.

Paper and email. The same guide says that if you must keep paper with card data, mark through the data with a thick black marker until it cannot be read and lock it in a drawer or safe few people can open. If a family emails a card number, process the payment, delete the email right away, and tell the sender how you prefer to take card details. The FTC’s guide for businesses says not to keep a card’s account number and expiration date without an essential business need, and to dispose of paper by shredding, burning, or pulverizing it.

Receipts. A business that accepts cards may print no more than the last 5 digits of the card number, and no expiration date, on an electronically printed receipt given at the point of sale (15 U.S.C. 1681c(g)).

Health details. Banks and the companies that process card payments for them fall outside HIPAA’s administrative simplification rules when they authorize, process, and settle payments for health care (42 U.S.C. 1320d-8). Your own records are different if your company is a HIPAA covered entity, which HIPAA for NEMT providers explains. Then three rules shape this form:

• Minimum necessary. Limit what you use and share for payment to what the purpose needs (45 CFR 164.502(b)). A card charge needs no diagnosis.
• Family members who pay. You may share information directly relevant to a family member’s involvement in paying for the rider’s care, if the rider agrees or does not object when given the chance (45 CFR 164.510(b)).
• Rides paid in full. If a rider or someone other than a health plan pays you in full for a ride and the rider asks you not to share it with a health plan for payment or operations, you must agree, unless a law requires the disclosure (45 CFR 164.522(a)(1)(vi)).

Debit cards and bank accounts charged on a schedule

A debit card or bank account charged on a regular schedule falls under Regulation E. Under 12 CFR 1005.10(b), preauthorized transfers from a consumer’s account may be authorized only by a writing signed or similarly authenticated by the consumer, and whoever obtains it must give the consumer a copy. The CFPB’s official comments add three points:

• A payee cannot sign the authorization on the consumer’s behalf after only an oral OK (comment 10(b)-3).
• An electronic signature that meets the federal E-SIGN Act counts, and the payer still gets a copy of the terms (comment 10(b)-5).
• The rule reaches debit cards used for recurring charges. A payee who was told a card was credit, when it was really debit, is excused only for a bona fide error with procedures to avoid it (comment 10(b)-7).

When amounts vary from one charge to the next, as ride charges do, Regulation E requires written notice of the amount and date at least 10 days before each charge that differs from the last one. The payee must tell the consumer about that right, but may offer notice only when a charge falls outside a set range (12 CFR 1005.10(d)). Part 6 gives the payer that choice. The payer can also stop a scheduled charge by telling their bank at least 3 business days before it (12 CFR 1005.10(c)).

Deposits, cancellation fees, surcharges, and disputes

Deposits. Visa’s rules call any charge for part or all of a service delivered later an advance payment. Only a short list of businesses may charge the entire price before the service is delivered: airlines, cruise lines, lodging, passenger railways, travel agencies, and vehicle rental, plus custom goods or services and a few other cases. Ask your processor before you charge a full ride price in advance. A partial deposit with the balance charged after the ride, on terms the cardholder signed, avoids the question.

Cancellation and no-show fees. Charge one only to a private-pay rider who agreed to it before booking, and only the amount agreed. Record your arrival time, how long you waited, and every call or text. The no-show policy template has the record to keep, and late cancellation explains how brokers use the term.

Surcharges. As of September 2026, Connecticut bars any surcharge for the way a customer pays (General Statutes 42-133ff), and Massachusetts bars sellers from surcharging a cardholder who pays by credit card (General Laws chapter 140D, section 28A). Where surcharges are legal, Visa’s rules for the United States cap a credit card surcharge at 3.00%, or at your average processing fee on credit cards if that is lower, and require written notice to your processor at least 30 days before you announce or start one. The surcharge must be disclosed where customers first reach you and again at checkout. Visa’s surcharge questions and answers (February 15, 2024) add that debit and prepaid cards cannot be surcharged, even when a debit card is run as credit.

Disputes. Under Regulation Z, a credit cardholder can dispute a charge for services not delivered as agreed. The written notice must reach the card issuer within 60 days after the first statement that shows the charge (12 CFR 1026.13). The signed form, the trip record, and your messages are your answer.

Riders you cannot charge on this form

Medicaid members are the main exception. Federal rule 42 CFR 447.15 limits Medicaid to providers who accept the program’s payment, plus any copay the state plan sets, as payment in full. CMS says states and providers may not charge members for no-shows (SMD 23-006, September 28, 2023). Broker agreements go further. MTM Health’s standard agreement, in the January 1, 2023 version Pennsylvania posts, bars billing or charging a member for its rides in any event, even when MTM or its client does not pay (section 6.C). The only exception is a copay or fee that MTM or its client authorizes.

Use this form for rides a person, a family, or a facility pays for on its own, and keep it out of any Medicaid or broker trip. Private pay NEMT explains when a Medicaid member may pay privately, and billing for no-shows covers the payer rules. Facilities that pay by invoice instead of card belong on the NEMT invoice template.

How long to keep the form, and how to throw it away

Keep the signed form for as long as the authorization lasts, because Visa’s rules require you to provide it to the cardholder or the card issuer on written request. After it ends, file it with the trip and payment records for the charges it covered, so you can answer a late dispute. Store paper forms in a locked drawer, and shred any copy you no longer need. NEMT credit card payments covers the rest of taking card payments from private riders.