Patient name: ______________________________
Date of birth: _______________________________
Practice Name: _____________________________
Patient Consent for Financial Communications
Financial Agreement
• I acknowledge, that as a courtesy, the practice may bill my insurance company for services provided to me.
• I agree to pay for services that are not covered or covered charges not paid in full including, but not limited to any
co-payment, co-insurance and/or deductible, or charges not covered by insurance.
• I understand there is a fee for returned checks.
Third Party Collection. I acknowledge the practice may use the services of a third-party business associate or affiliated
entity as an extended business office (“EBO Servicer”) for medical account billing and servicing.
Assignment of Benefits. I hereby assign to the practice any insurance or other third-party benefits available for health
care services provided to me. I understand the practice has the right to refuse or accept assignment of such benefits. If
these benefits are not assigned to the practice I agree to forward all health insurance or third-party payments that I
receive for services rendered to me immediately upon receipt.
Medicare Patient Certification and Assignment of Benefit. I certify that any information I provide, if any, in applying for
payment under Title XVIII (“Medicare”) or Title XIX (“Medicaid”) of the Social Security Act is correct. I request payment of
authorized benefits to be made on my behalf to the practice by the Medicare or Medicaid program.
Consent to Telephone Calls for Financial Communications. I agree that, in order for the practice, or Extended
Business Office (EBO) Servicers and collection agents, to service my account or to collect any amounts I may owe, I
expressly agree and consent that the practice or EBO Servicer and collection agents may contact me by telephone at any
telephone number, without limitation of wireless, I have provided or the practice or EBO Servicer and collection agents
have obtained or, at any phone number forwarded or transferred from that number, regarding the services rendered, or
my related financial obligations. Methods of contact may include using pre-recorded/artificial voice messages and/or use
of an automatic dialing device, as applicable.
A photocopy of this consent shall be considered as valid as the original.
Patient/patient representative signature: _______________________________ Date: _________________
If you are not the patient, please identify your relationship to the patient. Circle or mark relationship(s) from list below:
Spouse Guarantor
Parent Healthcare Power of Attorney
Legal Guardian Other (please specify) _______________________________
Last Updated: July 2017
