Health Care Financial Agreement Form

Form Template

Patients are responsible for covering all costs of services rendered that are not covered by their health care insurance.

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Language: English
Country: United States of America

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.

Features
  • Image Capture
  • Submission Editing
  • Reference Data
  • Dispatch
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Platforms
  • iPhone
  • iPad
  • Android
  • Windows
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Integrations
  • Quickbooks
  • Salesforce
  • Google Docs
  • Dropbox
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*The Capterra SoftwareAdvice ​and GetApp logos are a service mark of Gartner, Inc. and/or its affiliates and is used herein with permission.*

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