Forms > Financial Consent Form

Financial Consent Form


A financial consent form is a declaration to abide by the terms and conditions that are relevant to a contract or a business transaction. The financial consent form will contain all the relevant clauses that may appear as part of the business transaction during the life of a contract and needs both the parties to sign on it or it can be written in the letter head of one party with the other party signing on it. The following is a sample financial consent form with the transaction between a patient and a nursing home.

Sample Financial Consent Form

 

St Ann’s Nursing Home 

FINANCIAL CONSENT FORM

Thank you for choosing the services of St. Ann’s Nursing home. We always aim to deliver the best nursing services by using the latest equipment, up-to-date technology, and the best doctors. An important part of this mission is to make the cost of nursing care as minimal and affordable as possible.

Payment Options

You would like to make the payment using:

  • Cash
  • Check
  • VISA Card
  • Master Card


Terms and conditions:
  • St. Ann’s nursing home requires payment at the time of your treatment
  • We permit payment in maximum of three installments
  • We would be happy to work with your insurance companies (if any) to maximize your benefits and bill them for reimbursement for your treatment
For check writers:
We would be glad to accept your checks. When you provide us a check as payment, you authorize us to use the information from the check to make a one-time electronic transfer from your account, or to process the payment as a check transaction. You authorize us to collect a fee of $ ___ through electronic payment transfer from your account if your payment is returned unpaid.

Name of the patient: ___________________________

Signature of the patient or guardian: ______________

Date: ______________

Category: Financial Forms

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