Healthcare Payment Addendum

HEALTHCARE PAYMENT ADDENDUM

This Healthcare Payment Addendum ("Addendum") supplements the existing patient/provider relationship and governs financial responsibilities for services rendered by Provider Name: and Patient Name: . Effective Date: .

Purpose and Scope

This Addendum specifies payment policies, assignment of benefits, billing practices, and remedies for nonpayment for professional services, ancillary services, and supplies provided by the Provider. It establishes the patient or guarantor's financial obligations when insurance payment is delayed, denied, or does not cover service charges.

Patient and Contact Information

Insurance Information

Payment Terms

Patient is primarily responsible for all charges for services and supplies not paid by insurance. Provider will bill insurance as a courtesy but acceptance of insurance benefits does not relieve Patient of responsibility for unpaid balances, co-payments, co-insurance, deductibles, non-covered services, or charges applied as a result of claim denial or reduced benefits.

Cash Check Credit/Debit Card Insurance Assignment

I authorize Provider to charge my card or bank account for agreed charges, including recurring monthly payments for a payment plan, until this authorization is revoked in writing.

Payment Plans and Deferred Payment

Where Provider approves a payment plan, terms must be agreed in writing. The account remains subject to the terms below, and missed payments may accelerate the balance due and result in collection action.

Yes, I request a payment plan

Late Payment, Returned Checks, and Collections

Balances not paid within thirty (30) days of the statement date may be subject to late charges, collection agency referral, credit reporting, and recovery of reasonable collection costs, including attorney fees. Returned checks will incur a returned check fee.

Insurance Billing, Assignment of Benefits

Patient authorizes Provider to submit claims to insurance carriers and to receive payment directly from the insurer to the extent permitted by law. Patient assigns to Provider all rights and benefits to insurance payments for services rendered and directs payment to Provider. Patient understands that assignment does not relieve Patient of responsibility for charges not paid by insurance.

I assign benefits to Provider and authorize release of medical information necessary to process claims.

Privacy and Billing Notices

Patient acknowledges receipt of Provider's Notice of Privacy Practices and agrees that billing communications may be sent via telephone, mail, and electronic means as necessary for billing and collection purposes. Patient may revoke electronic communication consent in writing, but revocation will not affect disclosures made prior to revocation.

I acknowledge I have received the Provider's Notice of Privacy Practices and consent to billing communications as described above.

Dispute and Adjustment Policy

Questions concerning billing or disputes must be submitted in writing within forty-five (45) days of the statement date. Provider will investigate and respond to disputes in a timely manner, but payments not timely disputed remain due and may be subject to collection activity if unpaid.

Authorization Duration and Revocation

This authorization remains in effect until revoked in writing. Revocation does not affect actions taken in reliance upon this Addendum prior to receipt of a revocation. Authorization expiration date (if applicable): .

Certifications and Acknowledgments

By signing below, Patient certifies that the information provided in this Addendum is true and accurate to the best of their knowledge, that Patient understands financial responsibility for services provided, and that Patient authorizes Provider to bill the listed insurer(s) and to seek payment directly from insurance or from Patient as set forth herein. Patient understands that insurance payments may be applied to outstanding balances and that Patient remains liable for non-covered amounts.

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