Clinical\Financial Agreement (Financial) (08/31/20) Pg 1 of 2 380e
Client Name/DOB/ID (or affix label)
New Change Effective Date: _____/_____/_____
MEDICAID: ProviderOne # (example 123456789WA):_____________________________________
Amerigroup Community Health Plan of WA Coordinated Care of WA Molina 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:
Relationship to Client: Relationship to Client:
Subscriber DOB: Subscriber DOB:
Subscriber’s SSN #: Subscriber’s SSN #:
Plan or Group #: Plan or Group #:
Office use only:
Based on the Sliding Fee Worksheet, fees are set at ________% of the full fee.