Healthcare Payment Agreement

HEALTHCARE PAYMENT AGREEMENT

This Healthcare Payment Agreement ("Agreement") is entered into between Provider Name: and Patient Name: . Date of Service:

Patient Information

Female Male Other Prefer not to say

Emergency Contact

Insurance Information

Medical History (Brief)

Payment Terms and Financial Responsibility

By signing this Agreement, Patient accepts financial responsibility for all charges for services rendered by Provider that are not fully paid by insurance, including deductibles, copayments, coinsurance, non-covered services, and any balance remaining after insurer payment. Patient shall pay amounts due within days of receipt of a statement unless other arrangements are made in writing.

If the patient is uninsured or elects not to submit claims to insurance, Patient agrees to pay Provider's self-pay fees. Provider may apply discounts for self-pay at its discretion; such discounts do not alter the Patient's obligation to pay outstanding balances. Patient consents to Provider obtaining eligibility and benefit information from insurer(s) when necessary for billing.

In the event Patient fails to pay timely, Provider may refer the account for collection. Patient agrees to pay reasonable collection costs, including collection agency fees and attorney fees, to the extent permitted by law. Interest may accrue on unpaid balances as permitted by applicable law.

Payment Method & Payment Plan

Preferred payment method (check all that apply):

Cash Check Credit/Debit Card ACH / Bank Transfer Bill to Insurance

If a payment plan is requested, patient and Provider agree to the terms below. Patient requests a payment plan: Yes No

Assignment of Benefits & Authorization

Patient hereby assigns to Provider all rights and benefits otherwise payable to Patient under any insurance policy or third-party payer for services provided by Provider to the extent necessary to satisfy Patient's obligation under this Agreement.

Patient authorizes Provider to obtain and disclose medical and billing information to insurers, collection agents, or other entities as necessary to process claims, secure payment, or to comply with legal requirements. This authorization is valid through:

Check to authorize assignment of benefits and release of information: I authorize assignment and release

Billing, Statements and Refunds

Provider will render periodic statements showing charges, payments, adjustments, and current balance. Patient must notify Provider within days of receipt of any statement of disputes relating to charges. Any refund due to Patient will be issued in accordance with Provider's internal policies and applicable law after final claim adjudication.

No-show / Cancellation

Patient acknowledges that missed appointments, late cancellations, or no-shows may result in a fee. Such fees will be billed to Patient and are subject to the same terms and collection procedures as other balances.

Privacy & HIPAA Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices and consents to uses and disclosures of protected health information for treatment, payment, and healthcare operations as described therein. Patient understands rights concerning protected health information and may request restrictions or confidential communications.

Acknowledgment (select one): I acknowledge receipt of the Notice of Privacy Practices

Communications Consent

Patient consents to communications from Provider regarding appointments, billing, and health information by telephone, SMS, or email at the contact information provided above. Patient may withdraw consent by notifying Provider in writing.

Consent to electronic communications: I consent to electronic communications for billing and appointment reminders

Miscellaneous

This Agreement constitutes the entire agreement between Provider and Patient regarding payment responsibility for services rendered and supersedes prior communications on the same subject. Any modification must be in writing and signed by both parties. If any provision is held invalid, the remaining provisions remain enforceable to the fullest extent permitted by law.

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