Healthcare Pay Agreement

HEALTHCARE PAY AGREEMENT

Provider Name:    Patient Name:

Effective Date:    Account/Medical Record No.:

PATIENT INFORMATION

INSURANCE & GUARANTOR

MEDICAL HISTORY (RELEVANT TO BILLING)

FINANCIAL AGREEMENT & RESPONSIBILITY

By signing this Agreement, the undersigned Patient or Guarantor accepts financial responsibility for payment of charges for services rendered by the Provider. Insurance is accepted as a courtesy; however, acceptance of assignment of benefits does not relieve the undersigned of responsibility for any portion of the charges not paid by the insurer, including but not limited to copayments, deductibles, coinsurance, non-covered services, and services denied for lack of medical necessity.

Estimated patient portion for the scheduled service(s): $    Date estimate prepared:

Patient agrees to pay all copayments and estimated amounts at time of service. If the insurer pays in excess of the Provider's charge, Provider will refund the overpayment. If insurance denies coverage or pays less than expected, Patient agrees to pay the balance within 30 days of billing. Patient authorizes Provider to submit claims to the listed insurer and to obtain necessary information to process claims.

PAYMENT METHODS & PAYMENT PLAN

Accepted payment methods (select):
Cash    Check    Credit/Debit Card    Insurance Assignment

Late payment charge: Provider may assess a late fee of up to per month on outstanding balances or a flat fee of $ , whichever is permitted by law.

COLLECTIONS AND COSTS

If the account becomes delinquent and is placed with a collection agency or attorney, the undersigned agrees to pay reasonable collection costs, court costs, and attorney fees to the extent permitted by law. Provider may report delinquent accounts to consumer reporting agencies.

AUTHORIZATION, ASSIGNMENT OF BENEFITS, AND RELEASE

I hereby authorize Provider to release medical and other information necessary to process insurance claims and to obtain payment of benefits on my behalf. I request that payment of authorized benefits be made to the Provider when applicable. This assignment authorizes direct payment to the Provider and is not dependent on receipt of the patient's check or other payment.

I further authorize Provider to communicate with the insurance carrier, pharmacy, and other health providers as necessary to coordinate payment and care. I understand that signing this Agreement does not guarantee insurance coverage or payment by the insurer.

CANCELLATION, NO-SHOW, AND REFUND POLICY

Patient agrees to provide at least 24-hour notice for cancellations. Provider may charge a cancellation or no-show fee not to exceed $ . Refunds for overpayment will be issued in a timely manner following reconciliation of insurance payments and final billing.

PRIVACY & HIPAA ACKNOWLEDGMENT

Patient acknowledges receipt of Provider's Notice of Privacy Practices and authorizes the use and disclosure of protected health information for purposes of treatment, payment, and healthcare operations as necessary to process claims and provide care. Patient may revoke this authorization in writing, except to the extent that the Provider has already relied on the authorization.

DISPUTE RESOLUTION

Any dispute arising out of or relating to this Agreement shall be resolved first through good faith negotiation between the parties. If unresolved, the parties may submit the dispute to mediation or other non-binding dispute resolution. If litigation is necessary, the prevailing party shall be entitled to recovery of reasonable attorneys' fees and costs to the extent permitted by law.

ACKNOWLEDGMENT

By signing below, I certify that I have read and understand this Healthcare Pay Agreement, that the information provided above is true and correct to the best of my knowledge, and that I agree to be financially responsible for charges as described herein. I further certify that I have authority to sign on behalf of myself (or the patient) and to authorize the release of information and assignment of benefits as set forth above.

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