Financial Responsibility Agreement

Organization Name *

Account/Patient ID:

Date of Service/Agreement:

The person signing this document accepts primary financial responsibility for the account.

First Name of Responsible Party *

Last Name of Responsible Party *

Primary Phone Number *

Email Address *

Relationship to Patient/Recipient (if different):

Self

Parent

Legal Guardian

Other

Current Address:

Date of Birth:

Patient/Service Recipient Information

Full Name of Patient/Recipient:

Date of Birth

Patient/Recipient Address (if different):

Insurance and Payment Assignment

Primary Insurance Carrier:

Policy/Group ID:

Subscriber Name:

Secondary Insurance Carrier (if applicable):

Authorization for Assignment of Benefits: I hereby authorize direct payment of my insurance benefits to [Organization Name] for services rendered.

Yes

Terms of Financial Responsibility

Guarantor Obligation: I understand and agree that I am financially responsible for all charges for services rendered by [Organization Name] to the Patient/Recipient, regardless of insurance coverage.

Deductibles, Co-pays, and Non-Covered Services: I agree to pay all deductibles, co-payments, co-insurance, and any charges for services not covered or denied by my insurance company at the time the service is rendered, or upon receipt of a statement.

Timely Payment: I agree to pay the outstanding balance within [Specify Number] days of receiving the statement.

Proof of Coverage: I agree to provide current and accurate insurance information and assign payment directly to [Organization Name]. If insurance information is incomplete or inaccurate, the balance will be due in full from me.

Collections and Legal Fees: I understand that if my account is referred to a collection agency or attorney for non-payment, I will be responsible for all fees and costs associated with collection, including reasonable attorney fees.

Cancellation/No-Show Policy (If applicable): I understand and agree to the [Organization Name] policy regarding appointment cancellations and no-show fees.

Pricing (Optional for specific settings): I acknowledge that I have received and reviewed information regarding the costs and fees associated with the services being provided.

Yes

N/A

Signature and Acknowledgment

By signing below, I acknowledge that I have read, understand, and agree to the terms and conditions outlined in this Financial Responsibility Agreement.

Financial Responsibility Agreement

Financial Responsibility Agreement

New Patient Enrollment