"Credit or Loan for Health Care Services
The attached application and information is for a credit card or loan to help you pay for your health care treatment. You should know that:
You are applying for a ____ credit card or a ____ loan for $____.
You do not have to apply for the credit card or the loan. You may request a different place and additional time to review, fill out, and sign the application. You may pay your health care provider for treatment in another manner.
This credit card or loan is not a payment plan with the provider's office. It is credit with, or a loan made by, [name of company issuing the credit card or loan]. Your health care provider does not work for this company.
Before applying for this credit card or loan, you have the right to a written treatment plan from your health care provider. This plan must include the expected treatment to be provided and the estimated costs of each service. If you have insurance, the treatment plan must tell you how much your insurance is expected to cover. If you are a Medi-Cal patient seeking services from a Medi-Cal provider, your treatment plan must tell you if Medi-Cal will cover a different service to treat your condition. If you only want services covered by Medi-Cal, you should not sign up for this credit card or loan.
Your health care provider cannot charge your credit card or loan account before you start treatment.
You have the right to have your credit card or loan account refunded for any charges for treatment you did not get. However, your provider does not have to refund the amount they spent to prepare for your treatment. Your health care provider must refund the amount of the charges to the lender within 15 business days of your request. The lender must take refunded charges off your account.
Please read carefully the terms and conditions of this credit card or loan.
You may be required to pay interest rates on the amount charged to the credit card or the amount of the loan. If you pay late, you may have to pay a penalty and a higher interest rate.
You may use this credit card or loan to pay for future health care services.
If you do not pay the money that you owe on the credit card or loan, your missed payments can be reported and could hurt your credit rating. You could also be sued.
[Patient's Signature]"
Ca. Bus. and Prof'l. Code § 654.3