Addendum for Pre-Authorized Healthcare Transactions

Card-Brand Compliant Healthcare Program (“Rider”)

Exhibit A: Pre-Authorized Healthcare Form

Pre-Authorized Healthcare Form

Card-Brand compliant MediPay transaction options

Practice Name:

Patient Name:

Date of visit:

Your estimated portion for this visit: $

Check every authorization that applies.

In-network / Out-of-network / Self-pay

Guarantee any amount not covered by insurance

Covers: This visit only / All covered visits through ___ / ___ / ___

Ongoing treatments / recurring charges

$________ every ________ from ___ / ___ / ___ to ___ / ___ / ___

PRE-AUTHORIZATION CONDITIONS — Select one in each.

1. Cap — Your card may be charged up to:

the amount your insurance allows (out-of-network: the designated practice costs; self-pay: the services you receive)

$________ per visit

2. Invoice cadence — A confirmed balance within the cap is:

Charged to your card on file

Invoice first, then charged to your card if unpaid after ____ days

Invoiced only, never charged to your card

3. Invoice practices — If the final amount is lower than estimated, the difference is:

Refunded to your card on file

Applied as a credit on your account

Preview version. Actual form includes patient and card details, disclosures, and signatures.

1. Purpose & Scope

This Rider designates you (“Merchant“) as a Healthcare Processing Account and supplements your Merchant Processing Agreement to permit Pre-Authorized Healthcare Transactions under an approved Healthcare Processing Arrangement. You may process the following transaction types (“Enhanced Healthcare Transaction Types“), typically prohibited under standard retail merchant agreements; Card-on-File / Stored Credential, Pre-Authorized, Recurring, Card-Not-Present, and Post-Adjudicated healthcare transactions. When processed in accordance with this Rider, these transactions are classified as Healthcare Services (“Services“), not products, and benefit from additional chargeback protections.

2. Regulatory Authority

This Rider permits Enhanced Healthcare Transaction Types in a manner compliant with the following Card-Brand Rules:

Visa: Core Rules § 5.8.14.1; Interlink Operating Regulations, Pre-Authorized Healthcare Form requirements

Mastercard: Transaction Processing Rules § 5.3 Credential-on-File transactions

American Express Merchant Operating Guide § 4.5.3 Credential-on-File transactions

Discover: Operating Regulations § 9.11 Stored Card.

3. Healthcare Program Benefits

Participation in the Healthcare Program under this Rider:

Ensures compliance with Card-Brand, Acquirer, and PCI DSS standards under the Healthcare MCC classification, with tokenization and point-to-point encryption (P2PE) for cardholder data and HIPAA-aligned privacy practices.

Grants to Merchant a limited license to use MediPay’s proprietary Healthcare Program forms (the “Healthcare Program Forms”), including: The Pre-Authorized Healthcare Form (Exhibit A) and The Good Faith Estimate Patient Option Letter™.

The Healthcare Program Forms align with the Good Faith Estimate (GFE) requirements under the No Surprises Act (42 U.S.C. § 300gg-136), which include the option to cap the Pre-Authorized payment options consistent with the $400 variance guidelines. Pre-Authorized Healthcare Form is required, supporting evidentiary documentation in chargeback disputes under Visa § 11.1, et seq, Mastercard Chargeback Guide; American Express § 10.6, and Discover § 12.2.3.

Exhibit A: Pre-Authorized Healthcare Form

Pre-Authorized Healthcare Form

Card-Brand compliant MediPay transaction options

Practice Name:

Patient Name:

Date of visit:

Your estimated portion for this visit: $

Check every authorization that applies.

In-network / Out-of-network / Self-pay

Guarantee any amount not covered by insurance

Covers: This visit only / All covered visits through ___ / ___ / ___

Ongoing treatments / recurring charges

$________ every ________ from ___ / ___ / ___ to ___ / ___ / ___

PRE-AUTHORIZATION CONDITIONS — Select one in each.

1. Cap — Your card may be charged up to:

the amount your insurance allows (out-of-network: the designated practice costs; self-pay: the services you receive)

$________ per visit

2. Invoice cadence — A confirmed balance within the cap is:

Charged to your card on file

Invoice first, then charged to your card if unpaid after ____ days

Invoiced only, never charged to your card

3. Invoice practices — If the final amount is lower than estimated, the difference is:

Refunded to your card on file

Applied as a credit on your account

Preview version. Actual form includes patient and card details, disclosures, and signatures.

4. Merchant Duties

The Merchant agrees to:

Obtain and retain a signed Pre-Authorized Healthcare Form for each patient (valid for twelve (12) months).

Process all covered transactions through the approved Healthcare Account only.

Maintain PCI DSS and HIPAA-aligned credential controls and security.

Retain each authorization record for ninety (90) days beyond final settlement.

Cease billing immediately upon patient revocation or Acquirer notice.

Comply with all applicable laws, Card-Brand Rules, Merchant Processing Agreement, and Service Order Terms.

Failure to comply with the above may result in removal from the Healthcare Program.

5. Inclusion & Effectiveness

This Rider is incorporated by reference into your Merchant Processing Agreement. Execution of the Merchant Processing Agreement constitutes acknowledgment and acceptance of this Rider, which is effective upon underwriting, approval, and assignment to you of a merchant processing identification number.

Service Order Terms & Conditions apply — available at myriadsystems.ai/medipay-service-order-terms-conditions