Healthcare Funding Solutions

HEALTHCARE FUNDING SOLUTIONS

This Healthcare Funding Solutions Application and Authorization ("Agreement") authorizes the healthcare provider and its designated funding administrator to evaluate, arrange and, if approved, originate financing for the applicant's healthcare services. Completion of this form is an application for funding and includes patient authorizations necessary to verify insurance, benefits, and credit information, and to bill/pay third parties as required for funding.

Patient Information

Emergency Contact Phone:

Insurance Information

Employment and Financial Information

Funding Request

Requested Funding Amount: $

ACH / Bank Draft Credit / Debit Card Other:

Terms, Authorizations and Disclosures

By submitting this application, the applicant certifies that the information provided is true, complete, and accurate to the best of the applicant's knowledge. Applicant authorizes the healthcare provider and its funding administrator to obtain and verify financial, employment, credit, insurance, and medical billing information as necessary to evaluate and service the funding arrangement.

Funding is conditional upon approval by the funder. Applicant acknowledges that repayment terms, interest rates, fees, and schedule will be disclosed in the funding agreement should funding be approved. Applicant understands that failure to make payments as agreed may result in collection activity, reporting to credit bureaus, and legal remedies including recovery of collection costs and attorneys' fees where permitted by law.

Assignment of Benefits and Billing: Applicant authorizes assignment of benefits to the provider and authorizes the provider to submit claims to insurance and to receive payment directly from insurer(s). Applicant further authorizes the provider to apply insurer payments to the funding account and to provide remittance information to the funder for reconciliation and collection of patient responsibility.

I authorize the funder to obtain credit reports and other consumer reports necessary to evaluate creditworthiness.
I authorize verification of employment and income information for underwriting purposes.
I authorize automatic ACH debits (if ACH selected) from the account designated at the time of funding for scheduled payments.
I authorize assignment of insurance benefits and disclosure of billing information to the funder as necessary to process funding and payments.

HIPAA Authorization for Use and Disclosure of Protected Health Information

I authorize the release of my protected health information, medical records, and billing records to the healthcare provider's funding administrator, funder, and their agents for the purpose of determining eligibility for financing, claims adjudication, and payment processing. This authorization includes information relating to treatment, diagnosis, insurance claims, and payment history.

I understand that this authorization is voluntary and that I may revoke it at any time in writing, except to the extent that action has been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

This authorization will expire on:

Medical History (Relevant to Funding / Treatment)

Acknowledgment and Certification

By checking the box below and signing, I certify under penalty of perjury that the information provided herein is true and correct. I acknowledge receipt of a copy of this application and understand that approval is not guaranteed. If my application is approved, I agree to the terms disclosed in the final funding agreement.

I certify the information provided is accurate and I consent to the authorizations above.

Signature

By signing below, I authorize the actions described in this application and acknowledge that I have read and understand the terms and authorizations contained herein.

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