Texas patient financial agreement 2026

1. Click ‘Get Form’ to open the Texas Patient Financial Agreement in the editor.
2. Begin by entering the patient’s name and date of birth at the top of the form. This information is crucial for identifying the patient.
3. In section 1, initial next to the acknowledgment statement regarding insurance billing. This confirms your understanding of payment responsibilities for services not covered by insurance.
4. Proceed to section 2 and initial to acknowledge that third-party collection services may be used for billing. This ensures transparency about how your account may be managed.
5. In section 3, initial next to the assignment of benefits statement, indicating that you assign any insurance benefits directly to South Texas Cardiovascular Consultants.
6. For section 4, if applicable, initial next to the Medicare certification statement, confirming that all provided information is accurate for Medicare or Medicaid payments.
7. In section 5, initial your consent for telephone communications regarding financial obligations. This allows for efficient communication about your account.
8. Finally, sign and date at the bottom of the form. If you are signing on behalf of the patient, indicate your relationship as specified in the options provided.

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