Healthcare Medical Billing Agreement

HEALTHCARE MEDICAL BILLING AGREEMENT

This Medical Billing Agreement (the "Agreement") is made and entered into by and between Provider: and Patient / Responsible Party: . Effective Date:

Scope of Services

Provider authorizes the billing agent or Provider's billing department to bill insurance carriers, third-party payors, and/or the Patient for services rendered by Provider. The billing services include claim preparation and submission, insurance follow-up, posting of payments and adjustments, statement generation, and collection efforts as described below. The billing agent shall act as an agent of Provider for billing purposes only and shall not render medical services.

Patient Information

Insurance Information

Medical History (for billing context)

Patient Financial Responsibility

Patient agrees that insurance is a contract between Patient and insurer and that Patient is ultimately responsible for payment of all charges incurred that are not paid by insurer. This includes co-payments, deductibles, co-insurance, services not covered by the insurer, and any balance remaining after insurer payment.

Assignment and Authorization

By signing this Agreement, Patient assigns to Provider all rights to insurance benefits and authorizes payment of medical benefits directly to Provider to the extent of charges for services rendered. Patient authorizes Provider and its agents to release medical and billing information to insurers, collection agencies, attorneys, and other entities as necessary to secure payment for services.

I hereby assign benefits and authorize release of information as stated above.

Billing Practices, Statements, and Collections

Provider shall submit claims to the insurance carrier(s) designated by Patient. Patient shall cooperate in providing necessary information and signatures to process claims. Patient agrees to pay any amounts not paid by insurance within thirty (30) days of Provider's billing statement. Delinquent balances may be referred to collection, and Patient accepts responsibility for collection costs, reasonable attorney fees, and interest as permitted by law.

Insurance Denials and Non-Covered Services

In the event of denial, partial payment, or non-coverage by an insurer, Patient remains responsible for payment. Provider will make reasonable efforts to appeal denials with Patient cooperation. Any refunds due from insurer after collection of payment shall be handled according to Provider's refund policy.

Privacy and HIPAA Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices and authorizes the use and disclosure of protected health information for treatment, payment, and healthcare operations, including disclosures necessary for billing and collections. Patient may request restrictions or confidential communications in writing.

I acknowledge receipt of the Notice of Privacy Practices and consent to the uses and disclosures described above.

Term, Termination and Expiration

This Agreement shall remain in effect until terminated by either party upon thirty (30) days' written notice. Authorization to release information and assignment of benefits shall remain in effect for claims arising from dates of service rendered while this Agreement is in force. Authorization expiration date (optional):

Dispute Resolution and Governing Law

Any dispute arising under this Agreement shall be governed by the laws of the state specified below and, at the option of Provider, may be resolved in a court of competent jurisdiction or by binding arbitration. Governing law:

Notices

Notices shall be in writing and delivered to the mailing addresses provided in this Agreement or to other addresses provided in writing. Provider address:

Patient address:

Certification

By signing below, the parties certify that they are authorized to enter into this Agreement, that the information provided is accurate to the best of their knowledge, and that they understand and accept the terms and financial obligations set forth herein.

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