Healthcare Insurance Agreement

HEALTHCARE INSURANCE AGREEMENT

This Healthcare Insurance Agreement (the Agreement) is entered into between the Provider and the Patient. Provider Name: and Patient Name: . Effective Date: .

Patient Information

Insurance Information

Medical History (for billing and treatment)

Agreement Terms

Assignment of Benefits: Patient hereby assigns and directs all insurance and third-party benefits to be paid directly to the Provider for services rendered. Patient acknowledges that Provider may submit claims and accept insurance payments on Patient's behalf. This assignment does not relieve Patient of responsibility for charges not covered by the insurer, including but not limited to deductibles, co-payments, co-insurance, non-covered services, and amounts in excess of customary and usual charges. Patient initials to acknowledge assignment:

Authorization to Release Information: Patient authorizes Provider to release medical and billing information necessary to process claims and appeals with payors, to coordinate benefits, and to comply with legal requirements. This authorization includes disclosure of protected health information to insurers, billing agents, and collection entities as required to adjudicate claims. Patient consents:

Financial Responsibility: Patient acknowledges responsibility for payment of co-payments, deductibles, co-insurance, and any portion of charges not reimbursed by insurance. If insurance denies a claim or fails to pay in a timely manner, Patient remains responsible for payment within the timeframe stated on Provider invoices. If an outstanding balance is referred for collections, Patient will be responsible for reasonable collection fees and related costs to the extent permitted by law.

Billing and Payment Authorization: Patient authorizes Provider to submit claims, to store and use payment information provided to satisfy any patient-responsibility balance, and to obtain supplemental information from the insurer necessary to process claims. Patient authorizes direct payment to Provider when applicable:

Acknowledgment of Coverage Limitations: Patient understands that not all services will be covered under their insurance policy. Patient is responsible for verifying coverage and obtaining prior authorization when required. Provider has provided an estimate of expected charges when practicable; such estimates are not guarantees of payment.

Privacy, Authorization, and Expiration

HIPAA and Privacy Acknowledgment: Patient acknowledges receipt of Provider's Notice of Privacy Practices and understands how Protected Health Information may be used and disclosed for treatment, payment, and healthcare operations. Patient acknowledges:

Revocation: Patient may revoke this authorization in writing at any time by delivering a signed written revocation to the Provider. Revocation will not affect disclosures made in reliance upon this authorization prior to receipt of the revocation.

Governing Law and Dispute Resolution: This Agreement shall be governed by the laws applicable to the Provider's principal place of business. Any disputes arising under this Agreement shall be resolved in accordance with Provider's standard dispute resolution procedures.

Certifications and Signatures

By signing below, Patient certifies that the information provided in this Agreement is true and correct to the best of their knowledge, that Patient authorizes the statements and assignments contained herein, and that Patient has read and understands their financial responsibilities and privacy rights described above.

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