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.

5,000 Companies save time and money with GoCanvas

Lumen Logo Post Consumer Brands Logo Saluda Hill Landscapes Logo Te3co Logo Two Men and a Truck Logo VIP Lighting Logo

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.

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

Don't take our word for it...

“I’m not a tech guy and I was able to pick this thing up in probably an hour, and actually start to build apps. I’ve done them over lunch when I’ve gotten frustrated with a process that didn’t exist in our company. So for non tech people who’ve got a problem, the support here is awesome and I’d recommend it to anybody, not just in our industry.”

Dave Kramer, PennLine Service

Connect with one of our experts today.

We’ll help you put together the right solution for your needs.

Contact Us