Sample Financial Responsibility and Assignment of Benefits Forms

Every practice needs to have a Financial Responsibility Agreement with their patients, especially if you are out of network but even if you are in network and will be collecting co pays, co-insurance, or have patients who will first need to meet deductibles. Assignment of benefits forms are also essential if, on a case by case basis, your patient will be assigning benefits to you.
All forms are editable and downloadable.

Every practice needs to have a Financial Responsibility Agreement with their patients, especially if you are out of network but even if you are in network and will be collecting co pays, co-insurance, or have patients who will first need to meet deductibles. Assignment of benefits forms are also essential if, on a case by case basis, your patient will be assigning benefits to you.
All forms are editable and downloadable.

$15.00