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Urgent Care Financial Arrangement Form Mobile App

Have your urgent care patients complete financial agreement using the Urgent Care Financial Arrangement Form mobile app on a tablet or a smartphone. The app can be made HIPAA Compliant. Check out other Urgent Care Apps in our App store.

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Take a peek inside the Urgent Care Financial Arrangement Form Mobile App

Included Features

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Included Fields

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    If you have medical insurance, we are anxious to help you receive your maximum allowable benefits.

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    Payment is due in full at the time services are rendered unless payment arrangements have been ap...

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    Any such request must be accompanied by a current insurance card and all billing information need...

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    PLEASE CONTACT YOUR INSURANCE COMPANY TO VERIFY IF WE ARE AN IN-NETWORK PROVIDER (an insurance co...

  • Ico statictext

    Your insurance is a contract between you, your employer and the insurance company.

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    Our fees are generally considered to fall within the acceptable range by most insurance companie...

  • Ico statictext

    Patients who are Self-pay and those with insurance should be aware of the fact that we cannot gi...

  • Ico statictext

    We may need to release medical information concerning you to your insurance carrier as part of t...

  • Ico statictext

    We must emphasize that as medical care providers, our relationship is with you and not your insur...

  • Ico statictext

    If you have any questions about the above information, please do not hesitate to ask one of our i...

  • Ico signature

    Signature:

  • Ico date

    Date:

  • ...and More!

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