Lurie Children's Hospital

225 E Chicago Ave, Box 44, Chicago, IL 60611

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Security

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Lurie Children's Hospital

225 E Chicago Ave, Box 44, Chicago, IL 60611

(877) 924-8200

Security

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Service Link

Security

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Lurie Children's Hospital

225 E Chicago Ave, Box 44, Chicago, IL 60611

(877) 924-8200

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LCPC Autopay

225 E. Chicago Avenue Box 268 Chicago, IL 60611

LCPC MyChart

225 E. Chicago Avenue Box 268 Chicago, IL 60611

Lurie Children's Primary Care

225 E Chicago Ave Box 308 Chicago, IL 60611

LURIE CHILDRENS AUTOPAY

225 E. Chicago Avenue Suite #268 Chicago, IL 60611

LURIE CHILDRENS MYCHART

225 E. Chicago Avenue Suite #268 Chicago, IL 60611

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Lurie Children's Hospital

225 E Chicago Ave, Box 44, Chicago, IL 60611

(877) 924-8200

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Security

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Lurie Children's Hospital

225 E Chicago Ave, Box 44, Chicago, IL 60611

(877) 924-8200

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Lurie Children's Hospital

225 E Chicago Ave, Box 44, Chicago, IL 60611

(877) 924-8200

Payment Plan Authorization

Consent and Authorized Amount. By clicking "Confirm" below, I authorize my Service Provider to use my payment information provided above to electronically debit the specified bank account for the amount of my requested monthly payments and remit my payments to the designated healthcare provider.These payments will debit in the amounts and on the schedule described above. If a transfer date falls on a weekend or holiday, it may process on the next business day, or shortly thereafter. "Service Provider" means Lurie Children's Hospital and all its affiliated and related organizations.

I agree that it is my responsibility to maintain sufficient funds in my account until each transaction I authorize processes. I acknowledge that I am also responsible for all fees charged by my financial institution associated with the transactions authorized. If a payment is rejected due to insufficient funds, I agree that Lurie Children's Hospital may attempt to process the transaction again and may debit a returned item fee. I acknowledge that I will be liable for any fees, including insufficient funds or returned entry fees. I also authorize Lurie Children's Hospital to electronically debit or credit my account to correct any erroneous transfers.
Duration of Authorization; Termination and Modification. I understand that this authorization is valid and will remain in full force and effect until I notify Service Provider that I wish to revoke this authorization. To revoke or modify this authorization, please contact our agent InstaMed’s customer service at (866) 467-8263. I understand that Service Provider requires at least three (3) business days’ prior notice in order to update or cancel this authorization. This authorization will remain in effect until I terminate it. I understand that I have the right to terminate or modify this authorization, including updating my payment method, by logging into www.pay.instamed.com and modifying or discontinuing the payments or by notifying my Service Provider in writing to 225 E Chicago Ave, Box 44, Chicago, IL 60611 or calling (877) 924-8200. I understand that the termination of this authorization in no way relieves me of the obligation to fulfill my obligations to my Service Provider. My request to terminate or update this authorization will be effective only after my Service Provider has had a reasonable opportunity to act upon my request, at least three (3) business days.
Transactions and Accounts. I authorize my debit / credit card issuer and / or financial institution (bank) to honor transactions processed by this authorization. I certify that I am an owner of or authorized signer for the debit / credit card or the designated bank account with the Account Number and Routing Number listed under the ”Payment Method” on the “Review & Confirm” page. I acknowledge that a transaction involving an ACH debit from my bank account is subject to the Rules and Operating Guidelines of National Automated Clearing House Association and charge to my card is subject to the card brand rules and any agreement between me and my card issuer.
Acknowledgement. I understand that I should read this authorization carefully and keep a copy for my records. To receive a copy of this authorization for no charge I may contact my Service Provider at the address or phone number provided in Section 2 above.
Communications to be Provided Electronically. By enrolling, I also consent that, now and in the future, any information, notices, and disclosures in connection with this authorization may be provided to you electronically in lieu of providing such communications being provided on paper.
Updating Contact Information. I can change my contact information by configuring my account settings on this website or by writing to or calling my Service Provider using the information provided in Section 2 above.
Online and Mobile E-Sign Disclosure and Consent.

I acknowledge the following information is being provided by Service Provider:
1. Definitions for purposes of Section 7.
  - “Communication” is defined in Section 7(b) below.
  - “Electronic Delivery” is the act of delivering Communications using electrical, digital, magnetic, wireless, optical, electromagnetic, or similar electronic means as set forth in Section 7(d) below, including through our websites or mobile applications.
  - “We,” “us,” and “our,” refer to the entity that provides you one or more Services and such entity’s affiliates and subsidiaries or our agents, assignees or service providers.
2. Consent and Scope of Communications to be Provided Electronically.
  
  We are required by law, regulation or agreement to give you certain information “in writing”. With your consent, we can provide this information to you by Electronic Delivery instead. We also need your general consent to use electronic records and signatures in our relationship with you.
  
  You agree that for all Communications for Services we may use Electronic Delivery and, at our discretion, terminate paper delivery of Communications to you unless and until you withdraw your consent to this Section 7 as described in Section 7(f) below. This Section 7 applies to all Communications relating to such Services.
  
  “Communications” include, but are not limited to, the following:
  - All legal, regulatory or other disclosures associated with a Service;
  - All documentation or communications relevant to a Service, including agreements, amendments, policies and procedures (including but not limited to our privacy policy), terms and conditions, authorizations, confirmations of transactions, updates, notices, responses to claims, and transaction history;
  - Marketing materials; and
  - Any other document or other information required to be provided “in writing” or that we otherwise provide to you, or that you sign or submit or agree to at our request, in connection with Services or your relationship with us.
3. Delivery.
  
  Except as otherwise provided in this Section 7, physical delivery of Communications is not available for these Services. We reserve the right, but assume no obligation, to provide paper copies of any Communication that you have authorized us to provide via Electronic Delivery.
  
  To withdraw your consent to receive Communications by Electronic Delivery, you must follow the instructions set forth in the section titled “How to Withdraw Consent” in Section 7(f) below. Sometimes you are required to provide us with a written notice by law or under our agreement with you. Those notices must be provided to us on paper unless we tell you how to deliver the notice to us electronically.
4. Method of Electronic Delivery.
  
  All Communications (including alerts that Communications have been provided or posted) that we provide to you electronically will be provided by one or more of the following methods:
  - electronic messaging (such as e-mail, or SMS text or push notification to your mobile device);
  - by access to a web site, including our mobile websites or websites of third party service providers who we engage to deliver Communications through Electronic Delivery, that we will designate in a notice we send to you via electronic messaging at the time the information is available or that we will generally designate in advance for such purpose;
  - via our mobile applications; or
  - by requesting you download a Hyper Text Markup Language (“HTML”) file or Portable Document Format (“PDF”) or other specified electronic file containing the Communication.
  Communications delivered by e-mail will be sent to your e-mail address reflected in our records. You represent that any e-mail address you provide to us for Electronic Delivery purposes belongs to you or to a person who has authority for Services. You can update your email address on file with us by calling (866) 467-8263. You should print, download or otherwise retain a copy of this Section 7 and all other Communications provided by Electronic Delivery.
5. Hardware and Software Requirements.
  
  In order to access, view, print and retain electronic Communications, you must have:
  - Access to a device (e.g., computer, smartphone, mobile device, tablet, etc.) suitable for connecting to the internet, or downloading our mobile apps with the Current Version (as defined below) of (i) an operating system, such as Windows, Mac OS, iOS or Android, and (ii) a web browser, such as Chrome, Safari or Firefox, that we support;
  - A connection to the internet;
  - Local electronic storage capacity to retain Communications and/or a printer to print them;
  - A valid e-mail account and software to access it;
  - Software that enables you to view and display files in HTML and PDF format.
  By “Current Version,” we mean a version of the software that is currently being supported by its publisher. From time to time, we may offer services or features that require that your internet browser be configured in a particular way, such as permitting the use of cookies. If we detect that your Internet browser is not properly configured, we may provide you with a notice and advice on how to update your configuration. We reserve the right to discontinue support of a Current Version of software or an operating system if, in our sole opinion, it suffers from a security flaw or other flaw that makes it unsuitable for use.
  
  If our hardware or software requirements change, and that change would create a material risk that you would not be able to access or retain electronic Communications, we will give you notice of the revised hardware or software requirements. Continuing to use the Services after receiving notice of the change is reaffirmation of your consent with respect to other Communications.
6. How to Withdraw Consent.
  
  We will not impose any fee to process the withdrawal of your consent to receive Communications by Electronic Delivery. However, if you withdraw consent, your access to and use of the Services or certain features of the Services will be terminated. Any withdrawal of your consent to receive Communications by Electronic Delivery will be effective only after we have a reasonable period of time to process your withdrawal.
  
  At our option, we may treat the provision of an invalid e-mail address, or the subsequent malfunction of a previously valid e-mail address, as a withdrawal of your consent to receive Communications by Electronic Delivery.
  
  You may withdraw your consent to receive Electronic Delivery of Communications by calling us at (866) 467-8263.
7. Requesting Paper Copies.
  
  For Communications scheduled for Electronic Delivery, you should not expect to receive a paper copy of any Communication unless you request it. You can obtain a paper copy of an electronic Communication by printing it yourself or by requesting that we mail you a paper copy, provided that such request is made within a reasonable time after we first provided the Communication to you by Electronic Delivery. We may charge you a reasonable service charge, with prior notice of any such charge, for the delivery of paper copies of any Communication provided to you electronically pursuant to this Section 7.
  
  To request paper copies of electronic Communications, call us at (866) 467-8263.
8. Federal Law.
  
  You acknowledge and agree that your consent to this Section 7 is provided in connection with a transaction affecting interstate commerce, that it is subject to the federal Electronic Signatures in Global and National Commerce Act (the “E-SIGN Act”), and that you and we both intend that the E-SIGN Act apply to the fullest extent permitted by law.
9. Termination/Changes.
  
  We reserve the right, in our sole discretion, to discontinue providing you with electronic Communications, or to terminate or change the terms and conditions on which we provide electronic Communications. We will provide you with notice of any such termination or change as required by law.
10. Acceptance and Consent.
  
  By consenting to this Section 7, you agree to the following statements:
  - I have read, understand and agree to be bound by the terms and conditions contained in this Section 7, and consent to receive Communications and execute documents via Electronic Delivery according to the process described herein;
  - I am able to download and review files in HTML or PDF format, and I have internet access and can send and receive emails with links to websites;
  - Certain Communications may be delivered to me in paper form and in the future some or all of these Communications may be made available for me to view electronically in accordance with this Section 7;
  - My consent to receive Communications electronically does not automatically expire and is not limited as to duration;
  - I may incur costs, including but not limited to online time and other charges from my internet service provider or telephone carrier in accessing and/or viewing Communications;
  - I may terminate or suspend Electronic Delivery at any time at my discretion and I understand that this will terminate my access to the Site; and
  - We will not be liable for any loss, liability, cost, expense, or claim for acting upon this authorization or arising from my use of the product or services provided pursuant to this Section 7.

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What is Automatic Payment?

Automatic Payments is a feature that notifies you of future balances and automatically schedules a payment for your balance up to your Automatic Payment Limit.

Q: Which payment method will be used for the scheduled payment?
A: The automatically scheduled payment will be charged to the payment method you have on file.

Q: What is an Automatic Payment Limit?
A: The Automatic Payment Limit is the maximum amount a single payment will be scheduled for. If your new balance exceeds this amount, a payment will be scheduled for the maximum amount. This limit applies to each new balance.

Q: Can I edit my Automatic Payments enrollment after I sign up?
A: Yes, you can edit the maximum payment amount, payment method, or cancel your enrollment from this portal.

Q: How will I be notified of future balances?
A: A notification will be sent with your balance, the scheduled payment amount, and the date the payment is scheduled for.

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