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Desert Mountain Chiropractic 21321 E. Costello Rd. Suite 121 Queen Creek, AZ 85142 P: (480) 9879740 F: (480) 4571165PATIENT FINANCIAL AGREEMENT (Equitable Lien/Benefit Assignment Contract and Indemnification

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How to fill out patient financial agreement

01

Step 1: Obtain a patient financial agreement form from the healthcare provider.

02

Step 2: Read and understand the terms and conditions mentioned in the agreement.

03

Step 3: Fill in your personal information accurately, including your name, address, and contact details.

04

Step 4: Provide your insurance information, if applicable, including policy number and coverage details.

05

Step 5: Review the financial responsibilities section carefully, ensuring you understand your obligations.

06

Step 6: Sign and date the agreement to acknowledge your agreement to the terms and conditions.

07

Step 7: Make a copy of the agreement for your records and submit the original to the healthcare provider.

Who needs patient financial agreement?

01

Patient financial agreement is needed by any individual receiving medical services, regardless of whether they have insurance or not.

02

It is particularly important for patients who don't have insurance as it outlines their financial responsibilities and ensures clarity regarding payment expectations.

03

Both insured and uninsured patients can benefit from a patient financial agreement to understand their obligations and avoid confusion regarding medical billing and payments.

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What is patient financial agreement?

Patient financial agreement is a document that outlines the financial responsibilities of the patient for medical services received.

Who is required to file patient financial agreement?

The patient is typically required to sign and file the patient financial agreement.

How to fill out patient financial agreement?

The patient or their legal guardian must provide personal and insurance information and agree to the terms and conditions outlined in the agreement.

What is the purpose of patient financial agreement?

The purpose of patient financial agreement is to clearly communicate the financial expectations and responsibilities of the patient regarding their medical care.

What information must be reported on patient financial agreement?

Patient information such as name, address, insurance details, medical history, and signatures agreeing to the terms of payment.

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