Clarify financial responsibilities with our Financial Agreement and Assignment of Benefits form. This document ensures that parents or guardians agree to pay for therapy services either directly or through co-pays, while also authorizing your practice to bill their insurance provider for covered services.
Key features include:
- Payment agreement: Acknowledgment of the parent’s responsibility to pay for services, including any co-pays or charges not covered by insurance.
- Insurance billing authorization: Consent for your practice to bill the parent’s insurance for eligible services.
- Insurance updates: A requirement for parents to notify your practice of any changes to their insurance coverage.
- Financial responsibility for insurance gaps: Parents agree to cover any charges incurred due to insurance gaps or failure to report changes in coverage.
This form supports transparency and helps your practice manage billing efficiently, ensuring parents understand their financial responsibilities while streamlining the insurance process.
No. of Pages: 1
All sales are final. Due to the nature of our products and services, we are unable to offer refunds or exchanges.
Financial Agreement & Assignment of Benefits
$150.00Price