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):_____________________________________
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:
Plan or Group #: Plan or Group #:
Office use only:
Based on the Sliding Fee Worksheet, fees are set at ________% of the full fee.
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
Client or Responsible Party Printed Name
Parent/Legal Guardian Signature
Parent/Legal Guardian Printed Name
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