Patient Financial & Insurance Agreement

Patient Financial & Insurance Agreement
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Apt / Suite / Unit

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Payment Method: How do you intend to pay for services?*

Health InsuranceSelf-Pay
If patient is a minor, please enter responsible party's information below:
Responsible Party

First NameLast Name
Responsible Party Date of Birth

MonthDayYear
Date
Responsible Party Email
example@example.com
Responsible Party Phone Number
Please enter a valid phone number.
Health Insurance Information
Primary Insurance Plan*
Policy ID*
Member Number
e.g., 00 (Subscriber is 00, spouse is 01, etc.)
Group Number
Patient Relationship to Subscriber*
Subscriber Full Name*

First NameLast Name
Subscriber Date of Birth*

MonthDayYear
Date
Address Insurance Registered Under *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance Plan
Policy Number
Member Number
e.g., 00 (Subscriber is 00, spouse is 01, etc.)
Group Number
Patient Relationship to Subscriber
Subscriber Full Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Document Upload
Govt. Issued ID (License, Passport, State Issued ID*

Cancelof
Primary Insurance (front)*

Cancelof
Primary Insurance (back)*

Cancelof
Secondary Insurance (front)

Cancelof
Seocndary Insurance (back)

Cancelof
Insurance Responsibilities and Benefits Assignment

By providing my signature below, I certify that:
Assignment of Insurance Benefits:

I irrevocably assign and transfer to Aspire Medical Group all rights, title, and interest in the benefits due under my insurance policy for services provided by Aspire Medical Group.

Financial Responsibility:

I agree to pay Aspire Medical Group for all charges incurred or for amounts exceeding those covered by my insurance company. I accept financial responsibility for any fees arising from services provided to myself or my minor child (or ward) by the staff at Aspire Medical Group.

Copayments and Deductibles:

I understand that copayments are due at the time of service, and that deductibles/co-insurance must be met for high-deductible plans. I accept financial responsibility for charges not covered by insurance.

Authorization to Release Billing Information

I authorize Aspire Medical Group to release necessary billing information to my insurance providers.

Insurance Changes:

I acknowledge it is my responsibility to supply complete and accurate insurance information. If my insurance changes, I will notify Aspire Medical Group.

Confirmation of Coverage and Payment:

It is strongly advised that you confirm with your insurance provider whether the services you are seeking are covered under your plan before receiving treatment. If there is a balance due after insurance processing, Aspire Medical Group will notify you, and payment is required upon receiving the statement.

Acknowledgment of Responsibility

I understand that it is my responsibility to know my insurance benefits and to confirm coverage for services provided by Aspire Medical Group. Aspire Medical Group is not responsible for any claims denied by my insurance company. I understand that I am financially responsible for all charges incurred for services rendered, including those not covered by my insurance.
Electronic Signatures
By providing my electronic signature below, I agree to the terms and conditions outlined in this financial agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

The parties acknowledge and agree that this financial agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age (years)*
Patient Signature*

Clear
Date Signed*

MonthDayYear
Date
If the patient is a minor or is not legally competent to provide consent, the signature of a parent, guardian, or legal representative is required
Signature of Parent, Guardian, or Legal Representative

Clear
Parent, Guardian, or Legal Representative Name

First NameLast Name
Date Signed

MonthDayYear
Date
Relationship to Patient (Parent, Guardian, or Legal Representative)
Should be Empty:

Patient Financial & Insurance Agreement

If patient is a minor, please enter responsible party's information below:

Health Insurance Information

Document Upload

Insurance Responsibilities and Benefits Assignment

Electronic Signatures

If the patient is a minor or is not legally competent to provide consent, the signature of a parent, guardian, or legal representative is required