Healthcare Payment Contract

HEALTHCARE PAYMENT CONTRACT

This Healthcare Payment Contract (the Agreement) is entered into between Provider Name: and Patient Name: on Effective Date:

Patient Information

Insurance Information

Financial Responsibility and Payment Terms

Patient agrees to pay Provider for all services rendered as follows. Patient is responsible for co-payments, co-insurance, deductible amounts, and any services not covered by insurance. The standard co-pay at time of service is and applicable co-insurance is % of allowed charges. Any deductible applied by the insurer remains the responsibility of the patient.

If Provider bills Patient directly for balances remaining after insurance payments, Patient shall remit payment within days of the date of billing. Late payments shall incur interest at % per month or the maximum permitted by law, whichever is less.

Returned checks will incur a fee of plus any bank charges. In the event of account delinquency or assignment to collections, Patient is responsible for collection costs, including reasonable attorney fees and court costs.

Cash Check Credit/Debit Card on File Automated Draft/Autopay

Assignment, Authorization and Consent

Patient hereby assigns to Provider all rights and benefits to payment from Patient's insurance and authorizes Provider to submit claims on Patient's behalf. Patient authorizes Provider to obtain and exchange necessary information with insurers and other entities for billing and claim adjudication. Patient further authorizes Provider to apply insurance payments to outstanding balances and, if applicable, to bill Patient for any remaining balance.

Patient consents that Provider may contact Patient by telephone, mail, email, or text message regarding appointments, billing matters, and collection activity at the contact information provided. Patient may revoke communications consent in writing; revocation does not affect prior lawful communications.

Billing Disputes, Termination & Default

Patient must notify Provider in writing of any billing dispute within 60 days of the billing date. Failure to timely dispute a charge constitutes acceptance of the charge. Provider may suspend non-emergency services for accounts in default after due notice. Termination of services does not relieve Patient’s obligation to pay accrued charges.

In the event of default, Provider may pursue all legal remedies for collection. Any partial payment acceptance does not waive Provider's rights to pursue full payment.

Privacy and HIPAA Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices and understands that Protected Health Information may be used and disclosed for treatment, payment and healthcare operations as described in that notice. Patient authorizes disclosure of information necessary to process insurance claims and to coordinate care.

I acknowledge receipt of the Notice of Privacy Practices:

Authorization Expiration

This authorization to bill, assign benefits, and to disclose information for payment purposes shall expire on: unless earlier revoked in writing by the Patient as permitted by law.

Acknowledgment and Agreement

By signing below, Patient (or Patient's authorized representative) certifies that the information provided in this Agreement is true and accurate, acknowledges financial responsibility as described herein, authorizes Provider to bill and collect payment as set forth above, and understands Provider's billing and collection policies.

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