Healthcare CareCredit Document

Healthcare CareCredit Document

Provider Name:   Office Location:

Patient Information

Emergency Contact

Insurance Information

Medical History (Relevant to Financing)

Financing Authorization and Assignment

Financing Program:   I authorize the Provider to submit required personal, demographic and limited health information for the sole purpose of evaluating my application for credit and administering any approved financing. I understand that this authorization permits disclosure of limited protected health information necessary to underwrite and service the account, including dates of service, types of services, and provider information.

I hereby assign and authorize payment of insurance benefits to Provider to the extent permitted by my plan. I understand that assignment of benefits does not relieve me of financial responsibility for services rendered. I agree to be financially responsible for any amounts not covered by insurance and for any fees or interest assessed under the financing arrangements. I understand that Provider and the financing program are separate entities; approval of credit is determined by the financing program.

Authorization to Obtain Credit Information: I authorize the financing program to obtain my credit reports and other consumer report information for the purpose of evaluating my application. I understand I may be subject to a hard inquiry as part of that evaluation.

Authorization to Release Medical Information: I authorize Provider to release medical information necessary to the financing program for underwriting, billing, and account servicing.

Communications and Billing Consent

I consent to receive communications regarding my account, appointments, and financing by the following methods (select all that apply):

Phone calls to primary phone
Text messages to primary phone
Email to address on file

I understand that standard message and data rates may apply for text messages and that messages may be automated. I may revoke consent to electronic communications at any time by notifying the Provider in writing, subject to any restrictions under applicable law.

HIPAA Acknowledgment & Privacy

I acknowledge that the Provider has provided me with the Provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights with respect to that information. By signing below I authorize the Provider to use and disclose my PHI as described above solely for the purposes of treatment, payment, health care operations, and as necessary to process my financing application.

I acknowledge receipt of the Provider's Notice of Privacy Practices and authorize disclosures as described in this Financing Authorization.

Certifications and Signature

By signing below I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that falsifying information may result in denial of financing and may subject me to penalties. I understand that signing this form authorizes the Provider to submit information to the financing program and does not constitute a separate loan agreement with the Provider.

I retain the right to withdraw this authorization at any time by providing written notice to the Provider; however withdrawal will not affect disclosures already made in reliance on this authorization prior to receipt of the withdrawal notice. This authorization will expire on the date specified above or upon an event indicated in writing by the patient, whichever occurs first.

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