Healthcare Client Invoice Approval

HEALTHCARE CLIENT INVOICE APPROVAL

Client Name:    Patient DOB:

Invoice Number:    Invoice Date:    Account Number:

Patient Information

Female Male Other/Non-binary Decline to state

Insurance & Billing Information

Claim Submitted to Insurance: Yes    No

Medical History (For Billing Accuracy)

Invoice Line Items

Enter or verify billed items below. Mark any item you dispute.

Approval & Authorization

By signing below, the signing party certifies that the invoice information above has been reviewed and one of the following selections is made. The signing party acknowledges responsibility for any portion of charges not covered by insurance, pursuant to the provider's billing policy, and authorizes release of medical information required for adjudication of claims and collection efforts.

I approve the invoice in full and request prompt processing for payment of amounts due. I approve only the approved amounts entered above; I request adjustment for the remaining billed amounts. If partial approval selected, indicate patient responsibility below. I dispute one or more line items and have provided explanation below. I request an itemized clarification and review. I request an additional itemized statement for clarification of billed services.

Check Card on file Insurance only Other

Certification: I certify under penalty of law that the information provided on this form is true and correct to the best of my knowledge. I understand that knowingly submitting false or misleading information to obtain payment or to shift responsibility for payment may result in penalties and recovery actions. I authorize the provider to bill and communicate with my insurance carrier and to release health information necessary to process this claim. This authorization is effective on the date signed and remains in effect for the purposes of billing and collections until revoked in writing.

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