Can this form be signed electronically?

Yes. Under the federal ESIGN Act (15 U.S.C. §7001) and state UETA laws, electronic signatures are valid if intent, consent, attribution, and record retention are met. Exceptions such as wills or certain court filings may still require traditional execution.

What makes an eSignature legally binding?

An eSignature meets legal tests when the signer demonstrates intent to sign, consents to electronic transactions, the signature is attributable to the signer, and the record can be retained and reproduced. For consumer-facing records, ESIGN requires a disclosure and opt-out procedures.

Do health billing forms need special handling?

Yes. Billing forms that include protected health information must comply with HIPAA privacy and security rules. Covered entities should execute a Business Associate Agreement for third-party eSignature providers and limit PHI exposure, retaining records per 45 CFR §164.530(j).

Is notarization required for the form?

Not generally required for routine billing authorizations, but some states or payers may demand notarization or witness signatures for power-of-attorney or assignments. For remote notarization, verify state RON rules and recording requirements before relying on electronic notarization.

How long must we keep completed forms?

Retention depends on document type and applicable laws. Keep billing records for at least three years for tax purposes (IRC §6501(a)), seven years post-termination for many contracts, and six years for HIPAA-covered records (45 CFR §164.530(j)).

What if information changes after signing?

Submit an updated Billing Application Form with the corrected information and a new signature from the authorized signer. Maintain versioning and a clear audit trail; note effective date of change to avoid disputes over billing periods and payment obligations.

Electronic Signature
Templates
Finance
Billing Application Form

Billing Application Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

BILLING APPLICATION FORM

Complete this Billing Application to request establishment of a billing account and/or credit terms. The Applicant certifies that the information provided is true and complete, authorizes verification of credit and trade references, and agrees to the Terms and Conditions stated below.

1. Entity Information

Entity Type: Individual Sole Proprietor Partnership Corporation LLC Other

Legal Business / Applicant Name DBA / Trade Name (if any)

Tax ID / EIN / SSN

State of Formation / Incorporation

Year Established

Primary Business Address Billing Address (if different)

Phone

Fax

Email for Invoices

2. Billing Account & Payment Terms

Requested Account Name

Requested Credit Limit

Preferred Billing Cycle Monthly Bi-weekly Weekly Other

Payment Terms Requested: Net 30 Net 15 COD Other

Invoice Delivery Method: Email U.S. Mail EDI/Batch Customer Portal

Standard company policy: Past due balances will incur interest at the lesser of 1.5% per month or the maximum rate permitted by law, plus collection costs, court costs and reasonable attorneys’ fees. Applicant agrees to pay all charges in accordance with accepted terms when credit is granted.

3. Primary Billing Contact

Contact Name

Title

Phone

Email

4. Banking & Credit References

Bank Reference:

Bank Name

Bank Contact / Phone

Bank Address

Trade/Credit Reference 1

Trade/Credit Reference 2

5. Payment Method & ACH Authorization

Preferred Payment Method: Check ACH (Bank Transfer) Credit Card Wire

If ACH selected, provide account information and attach a voided check:

6. Resale / Tax Exemption

Sales Tax / Resale Certificate: Certificate attached Not applicable

Resale / Exemption Number

7. Credit Authorization & Certification

By signing below, Applicant hereby:

Authorizes the Company to investigate Applicant’s credit history and to contact banks and trade references for credit information and verification.
Certifies that all information in this application is true, complete and correct and acknowledges that any false statement may be grounds for denial of credit or termination of credit privileges.
Agrees to pay invoices in accordance with approved payment terms. Applicant agrees to pay interest, collection costs, court costs and reasonable attorneys’ fees in the event of delinquent payment and collection action.
Agrees to notify the Company in writing of any material change in ownership, financial condition, or other information supplied herein. Applicant will remain liable for all obligations incurred prior to such notice and any resulting changes in credit terms.

Authorization to Obtain Credit

The undersigned authorizes the release of credit information and banking references to the Company and acknowledges that this authorization remains in effect until revoked in writing by the Applicant. Applicant further acknowledges that personal guarantees or additional security may be required as a condition to granting credit.

Additional Remarks (explain any special circumstances)

8. Terms & Conditions (Summary)

These Terms & Conditions constitute a summary of the Company's standard billing and credit terms. Acceptance of credit is at the sole discretion of the Company. Approved credit terms will be documented in the account notice provided to Applicant. Applicant agrees that invoices are due in accordance with the approved terms, and that the Company may suspend or terminate credit privileges for nonpayment or breach of these terms. Applicant grants the Company a security interest in goods sold, to secure payment for goods and services supplied until account is paid in full. Governing law: the laws of the jurisdiction in which the Company maintains its principal place of business. Venue for disputes: the courts of that jurisdiction. If any provision is held invalid, the remaining provisions shall continue in full force.

9. Certification & Signature

The undersigned certifies under penalty of perjury that the information provided in this Billing Application is true and complete and that the signer is authorized to execute this application on behalf of Applicant.

Applicant Printed Name:

Signature:

Date:

What the Billing Application Form Is

The Billing Application Form is a standardized document used to request, authorize, or update billing arrangements between a service provider and a payer. It collects payer identification, billing contact details, account numbers, billing address, preferred invoice delivery method, payment terms, and any authorization signatures. Organizations use it to establish invoicing permissions, set up automated payments, and verify tax or healthcare billing identifiers. When completed accurately, the form helps prevent billing errors, supports compliance with recordkeeping rules, and creates an auditable trail for disputes and payment processing.

Why a Clear Billing Application Form Matters

A clear Billing Application Form reduces invoicing delays, minimizes incorrect charges, and documents payer consent for billing arrangements. It supports auditability and helps meet regulatory recordkeeping requirements for tax and healthcare billing while clarifying payment terms between parties.

Who Typically Completes This Form

Typical users include accounts receivable teams, billing administrators, healthcare providers, and third-party payers who manage invoicing.

Small businesses setting up customer invoices and payment authorizations electronically.
Healthcare clinics collecting patient billing authorizations and insurance assignment details.
Enterprises integrating billing with ERP systems and accounts payable workflows.

Identifying the correct user role ensures the form is completed by authorized personnel and routed to appropriate billing systems for processing.

Step-by-Step: Complete and Submit the Form

Follow these steps to complete and submit the Billing Application Form accurately and in compliance with billing policies.

01

Gather Documents: Collect IDs, tax forms, account statements, and authorization letters.
02

Enter Details: Provide legal names, addresses, account numbers, and contact phone.
03

Choose Billing: Select invoice delivery and payment method; note payment terms.
04

Sign & Submit: Obtain authorized signature, date the form, and submit to billing.

Typical eSubmission Flow for the Form

Typical eSubmission flow for a Billing Application Form from sender to accounting and archival systems.

Upload Document: Upload PDF or DOCX and select fillable fields.
Assign Signers: Add signer emails and set signing order.
Authenticate: Choose verification: email, SMS code, or KBA when required.
Archive: Store signed copy with audit trail and metadata.

Common Workflow Settings to Configure

Common workflow settings to configure when automating billing application intake and approvals in enterprise systems.

Field	Configuration
Signer Authentication	Email verification, SMS code, or knowledge-based authentication
Signing Order	Sequential or parallel signer routing with reminders
Auto-Archive	Save signed PDF to cloud storage with metadata tags
Notifications	Email notifications to signers and billing contacts

Comparing eSignature Pricing and Basic Features

Annual billing comparisons for common eSignature features and starting prices to evaluate per-user and per-invite cost models.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	Yes, 7-day trial	No	No	Yes, limited	Yes, limited
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
Envelope Cap	No cap	100 env/user/yr	Varies by plan	Varies by plan	Varies by plan

Security and Compliance Basics

Encryption in Transit: TLS 1.2 and 1.3 protocols

Encryption at Rest: AES-256 encrypted at rest

HIPAA: HIPAA-compliant with BAA available

Certifications: SOC 2 Type II, ISO 27001, PCI DSS

Regulatory Acts: ESIGN and UETA legal compliance

Accessibility: WCAG 2.0 Level AA support

Key Penalties and Risks for Errors

Incorrect TIN: Triggers backup withholding at 24%

Late 1099: $60–$330 per form depending on delay

Intentional Disregard: $660+ per form, no maximum

I-9 Violations: $281–$2,789 per violation

Notarization Missing: May render signature invalid in some jurisdictions

Data Breach Risk: Regulatory fines and breach notification costs

Common Preparation Pitfalls to Avoid

Using informal or mismatched names (initials, nicknames, DBA) causes payer rejections and can trigger backup withholding or require amended tax reporting.
Failing to verify billing addresses and account numbers leads to misdirected invoices, payment delays, and additional collection effort that increases operational costs.
Skipping required authentication (email alone when KBA is needed) weakens evidentiary value in disputes and may not meet payer or regulatory requirements.
Attaching incomplete supporting documents such as missing authorization letters or expired IDs delays approval and can require re-execution, creating audit complications.

Frequently Asked Questions and Answers

Answers to common questions about completing, signing, and submitting the Billing Application Form, including eSignature and compliance concerns.

Need help? Contact support

Can this form be signed electronically?
Yes. Under the federal ESIGN Act (15 U.S.C. §7001) and state UETA laws, electronic signatures are valid if intent, consent, attribution, and record retention are met. Exceptions such as wills or certain court filings may still require traditional execution.
What makes an eSignature legally binding?
An eSignature meets legal tests when the signer demonstrates intent to sign, consents to electronic transactions, the signature is attributable to the signer, and the record can be retained and reproduced. For consumer-facing records, ESIGN requires a disclosure and opt-out procedures.
Do health billing forms need special handling?
Yes. Billing forms that include protected health information must comply with HIPAA privacy and security rules. Covered entities should execute a Business Associate Agreement for third-party eSignature providers and limit PHI exposure, retaining records per 45 CFR §164.530(j).
Is notarization required for the form?
Not generally required for routine billing authorizations, but some states or payers may demand notarization or witness signatures for power-of-attorney or assignments. For remote notarization, verify state RON rules and recording requirements before relying on electronic notarization.
How long must we keep completed forms?
Retention depends on document type and applicable laws. Keep billing records for at least three years for tax purposes (IRC §6501(a)), seven years post-termination for many contracts, and six years for HIPAA-covered records (45 CFR §164.530(j)).
What if information changes after signing?
Submit an updated Billing Application Form with the corrected information and a new signature from the authorized signer. Maintain versioning and a clear audit trail; note effective date of change to avoid disputes over billing periods and payment obligations.

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