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Health Care Financial Agreement Form Mobile App

Patients are responsible for covering all costs of services rendered that are not covered by their health care insurance. The health care provider can inform patients of which payment options are available to them, payment due dates, health care services available and more, both before or after being seen by the provider.

Patients must sign off on a health care agreement covering this type of information. The Health Care Financial Agreement Form mobile app is a customizable template that health care providers can use at their offices to replace traditional paperwork.

The primary purpose of the Health Care Financial Agreement form is to serve as a contract document stating that the patients accept full responsibility for payment to the health care facility providing treatment. It template also includes an electronic signature capture for patients to sign off within the app.

The mobile app can be opened on a smartphone, tablet or desktop computer. This makes it convenient for the patient. Simply hand the patient the mobile device to complete in the waiting room.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Health Care Financial Agreement Form Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    Financial Agreement Form

  • Ico statictext

    I agree to pay for all services rendered.

  • Ico textbox

    I certify that I am 18 years of age and/or the legal guardian/guarantor.

  • Ico textbox

    Patient Name:

  • Ico camera

    Signature of Patient and/or Legal Guardian:

  • Ico date


  • Ico textbox

    Facility Name:

  • Ico textbox

    Name on Card:

  • Ico dropdown

    Credit Card Type (Select One):

  • Ico textbox

    Credit Card #:

  • Ico date

    Expiration Date:

  • Ico textbox

    CCV #:

  • ...and More!

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