Healthcare Payments Authorization Form

HEALTHCARE PAYMENTS AUTHORIZATION FORM

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy/ID Number:    Group Number:

Billing & Contact for Statements

Send Statements to:    Billing Address:

Payment Method (select all that apply)

Credit / Debit Card
Bank Account (ACH)
Assignment of Insurance Benefits
Other (specify below)

Cardholder / Bank Details

Card Number:    Expiration: /    CVV:

Routing Number:    Account Number:    Account Type:

Payment Authorization Details

I, the undersigned patient or authorized representative, authorize the healthcare provider and its billing agent to charge the payment method(s) indicated above for services rendered, patient responsibility balances (including co-payments, deductibles, coinsurance, and non-covered services), and any previously outstanding balances pursuant to the provider's billing policies. This authorization includes the right to: (a) submit charges to my insurance and apply any insurance payments to my account; (b) charge the credit or debit card on file and/or initiate ACH debits from the designated bank account; and (c) store authorization and payment information for future permitted charges consistent with this authorization.

This authorization is a limited, revocable payment authorization. I understand that I may revoke this authorization at any time by providing a written notice to the provider's billing department. Revocation will not affect charges processed prior to receipt of the revocation. I authorize the release of billing information to banks, card processors, and insurance carriers as necessary to complete transactions and process claims. I further authorize the provider to obtain a copy of my driver's license or other identification to verify cardholder identity when necessary.

If a charge is returned for insufficient funds or otherwise reversed, I understand that I remain responsible for the payment and any associated fees and collection costs, including reasonable attorneys' fees where permitted by law. Disputes regarding individual transactions must be submitted in writing within thirty (30) days of the transaction date; submission of a dispute does not suspend my obligation to pay undisputed charges.

Authorization Type:    One-time    Recurring

HIPAA Acknowledgment

I acknowledge that I have been provided with the provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed with respect to payment and billing. I authorize the release of medical information necessary to process insurance claims and to substantiate charges related to services rendered.

Authorization Expiration Date:

Acknowledgment and Certification

By signing below I certify that I am authorized to provide the payment method information supplied and that the information is true and correct. I understand that this authorization will remain in effect until I cancel it in writing. I expressly permit the provider and its agents to contact me at the telephone numbers and email addresses listed above regarding billing, payment collections, and appointment reminders, including by automated dialing or prerecorded message where permitted by law.

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