Healthcare Funds Authorization

Healthcare Funds Authorization

Patient Information

Insurance Information

Authorization — Funds and Payment

I authorize the healthcare provider named below to collect, apply, and/or charge funds toward my account for services rendered. Provider / Facility Name: .

Authorization applies to the following funding sources (check all that apply) and any transactions reasonably necessary to process payment for covered charges:

Payment Details

I authorize payment in the amount of: $ — Select one: One-time Recurring

Authorization Expiration (if any): . If left blank, this authorization will remain in effect until revoked in writing as set forth below.

Assignment of Benefits & Release

By signing below, I assign to the Provider all rights to payment from my insurer(s) and other third-party payors for services rendered and authorize direct payment to the Provider to the extent of such benefits. I authorize the release of medical and billing information necessary to adjudicate claims and process payment. This assignment does not relieve me of my obligation to pay any amounts not covered by third-party payors.

I understand Provider may submit claims, appeals, and requests for pre-authorization on my behalf and may obtain or disclose health information only to the extent necessary to process claims or secure payment. I further authorize Provider to endorse or deposit checks issued in payment of benefits to my account.

Financial Responsibility & Acknowledgments

I acknowledge that I remain responsible for all charges for services provided, including charges not covered or allowed by insurance or other funding sources. I agree to notify Provider of changes to insurance, account numbers, or funding status prior to the next scheduled payment. I agree to pay any administrative fees related to failed transactions, where permitted by law.

I understand that this authorization is voluntary and may be revoked at any time by providing written notice to Provider. Revocation will not affect actions taken by Provider in reliance on this authorization prior to receipt of the revocation, nor will revocation affect the obligation to pay for services already rendered.

Dispute Resolution & Miscellaneous

Any dispute arising out of this authorization related to payments or billing shall be handled in accordance with Provider's standard dispute policies. This authorization is binding on my heirs, assigns, and legal representatives. If any provision is found invalid, the remaining provisions remain in full force.

Privacy Acknowledgment

I acknowledge that I have received or been offered a copy of the provider's privacy practices and understand health information may be disclosed as necessary to process payment and claims. I consent to the use and disclosure of my protected health information for payment and healthcare operations consistent with applicable privacy laws.

Certification

By signing below I certify under penalty of perjury that the information I have provided is true and correct to the best of my knowledge. I authorize the actions described in this Healthcare Funds Authorization and confirm I have the legal authority to execute this document for the identified patient.

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