Healthcare Financial Contract

HEALTHCARE FINANCIAL CONTRACT

Parties and Effective Date

Provider Name:    Patient / Responsible Party:

Effective Date:

Patient Information

Insurance Information

Medical & Billing Authorization

The undersigned authorizes Provider to bill and collect from the patient, guarantor, or the identified insurer for all services rendered. The undersigned assigns to Provider all rights and benefits to insurance payments for services rendered, including benefits otherwise payable to the patient or subscriber. The undersigned consents to the release of medical and personal information necessary to process claims and to collect payments.

Financial Terms and Patient Responsibility

Patient is financially responsible for all charges not paid by third party payors, including but not limited to co-payments, co-insurance, deductibles, non-covered services, and charges denied by insurance for any reason. Provider will make reasonable efforts to estimate patient responsibility in advance; estimates are not guarantees. Patient agrees to pay amounts due according to the billing terms below.

Self-pay    Bill insurance    Third-party payer / Worker’s comp

Payment Terms; Late Payment; Collections

All co-payments and estimated patient balances are due at the time of service. Accounts unpaid after thirty (30) days may be charged interest at a rate of 1.5% per month (18% per annum) or the maximum permitted by law, whichever is lower. If account is referred to collections, patient is responsible for collection costs, reasonable attorney fees, and court costs. Provider may suspend non-emergency care for accounts in arrears in accordance with applicable law.

Payment Plan Option

Patient may request a payment plan subject to Provider approval. Terms established in writing will supersede standard billing terms.

Yes    If yes, Monthly Payment: $    Frequency:    Start Date:

Non-Covered Services, Estimates and Refunds

Patient acknowledges that certain services may be non-covered by insurance. Provider will provide an estimate when practicable. Overpayment will be refunded to the payor of record, or at Provider’s discretion, directly to patient. Refunds may be offset against outstanding balances.

Insurance Claim Submission and Cooperation

Patient agrees to cooperate with Provider in submitting insurance claims, providing accurate insurance information, and responding to requests. Patient authorizes Provider to appeal denied claims on patient’s behalf. Provider is not responsible for denials due to patient misrepresentation or failure to provide necessary information.

Privacy & HIPAA Acknowledgment

By signing below, patient acknowledges receipt of Provider’s Notice of Privacy Practices and authorizes the use and disclosure of protected health information for treatment, payment, and health care operations as necessary to carry out billing, collections, and care coordination.

I acknowledge receipt of the Notice of Privacy Practices.

Dispute Resolution; Governing Law

Any dispute arising under this Contract shall be governed by the laws of the state where Provider maintains its principal place of business. Parties shall attempt good faith negotiation prior to initiating litigation. Nothing in this section prevents Provider from pursuing immediate relief to protect health or safety.

Miscellaneous Provisions

Severability: If any provision of this Contract is held invalid, the remainder shall remain in full force. Amendment: This Contract may be amended only by a signed written agreement. Notice: Any notice required hereunder shall be in writing and delivered to the last known address of the party.

Medical History (Relevant to Billing)

Certifications and Acknowledgement

The undersigned certifies that the information provided is complete and accurate to the best of their knowledge. The undersigned authorizes Provider to apply payments and credits as permitted by this Contract, and understands that signature constitutes a contractual obligation to pay for services rendered in accordance with the terms above.

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