FINANCIAL AGREEMENT
Clinical\Financial Agreement (Financial) (08/31/20) Pg 1 of 2 380e
Client Name/DOB/ID (or affix label)
Client Insurance:
New Change Effective Date: _____/_____/_____
MEDICAID: ProviderOne # (example 123456789WA):_____________________________________
APPLE MCO PLAN:
Amerigroup Community Health Plan of WA Coordinated Care of WA Molina Healthcare
United-Optum Healthcare
I agree to present my insurance eligibility card the first of each month.
MEDICARE: MBI: _____________________ SUPPLEMENTAL INS:_______________________
I request payment of authorized MEDICARE benefits be made directly to the agency appointed by me.
I authorize the holder of medical information about me to release to the HEALTH CARE FINANCING
ADMINISTRATION and its agents any information needed to determine these benefits payable to related services.
I understand that I will be responsible for the annual deductible and co-payment not paid by supplemental insurance.
I understand that fees are based on current MEDICARE allowances.
COMMERCIAL INSURANCE: I understand I am responsible for any co-pays and deductibles as defined by my
insurance policy. I understand I am responsible for obtaining pre-authorization for services, and that failure to do so may
result in the full fee being charged to me.
Primary Commercial Insurance Secondary Commercial Insurance
Insurance ID#: Insurance ID#:
Insurance Company: Insurance Company:
Insurance Co. Phone: Insurance Co. Phone:
Subscriber Information (if insurance is under someone other than the client):
Subscriber Name: Subscriber Name:
Subscriber Address:
Subscriber Address:
Relationship to Client: Relationship to Client:
Subscriber DOB: Subscriber DOB:
Subscriber’s SSN #: Subscriber’s SSN #:
Subscriber’s Employer:
Subscriber’s
Employer:
Plan or Group #: Plan or Group #:
SELF-PAY/UNINSURED:
Office use only:
Based on the Sliding Fee Worksheet, fees are set at ________% of the full fee.
FINANCIAL AGREEMENT
Clinical\Financial Agreement (Financial) (08/31/20) Pg 2 of 2 380e
Client Name/DOB/ID (or affix label)
All Clients:
I authorize release of medical information necessary to process my claim.
I agree to the assignment of all insurance payments to Compass Health, PO Box 3810, Everett WA 98213. I
authorize my insurance carrier to pay benefits directly to the agency. I agree to forward any insurance payments
I might receive directly to the agency. Insurance does not guarantee benefits. I am responsible for fees not
covered by insurance.
It is my responsibility to inform the agency of any changes in my financial status.
I understand that my portion of the fee is due at the time of service and agree to pay promptly all fees for which
I am responsible; failure to do so may result in termination of services.
If I lose Medicaid while in services with Compass Health, I understand I am fully responsible for all fees
incurred, and that income verification may be required.
A copy of Compass Health’s fee schedule is posted at the office and is available upon request. I understand
that these fees are subject to change based upon the revision of the fee schedule.
I understand that I may be charged a NO-SHOW FEE for missed or canceled appointments unless 24
hours’ notice is given.
I have read and agree to the above conditions. Unpaid fees are subject to collection.
Client or Responsible Party Signature
Date
Client or Responsible Party Printed Name
Parent/Legal Guardian Signature
Date
Parent/Legal Guardian Printed Name
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome