Financial Management Forms Package – Spanish
$67.00
These client-facing Spanish-language forms support clearer communication with Spanish-speaking clients. This collection may not include all forms available in the original Documentation Wizard packages. Please review the original Financial Management Forms Package to ensure your documentation set is complete.
The Documentation Wizard Financial Management Forms Package provides the foundation and organization for the financial arrangements with your client. They cover the needs of clients who use insurance and those who pay privately. They have been extensively reviewed and approved by an attorney, a bioethicist, and a billing expert.
Documentation Wizard Financial Management Forms Package includes:
- Assignment of Benefits and Billing Authorization
- Credit Card Authorization
- Invoice for Services
- Superbill
- Insurance Opt-Out Form
Customization
Please customize these documents for your specific practice needs and state requirements. We’ve highlighted areas in yellow that typically need your attention for easy identification. Content outside the yellow-highlighted areas should remain unchanged to maintain the integrity and legal accuracy of the documents. The copyright notices must remain on all forms and may not be removed. These forms are the intellectual property of Documentation Wizard, LLC. You may share them with clients to complete and for your own clinical use, but you may not sell, give away, or redistribute the forms themselves, whether original or modified. These forms are provided as templates only and do not constitute legal advice. For legal guidance specific to your situation, please consult with an attorney in your state.
BONUS: Form Personalization! You’ll be asked at checkout to provide your practice information (licensure and number, NPI#, address, and contact information) so headers on client-facing forms can be personalized for your practice.
Let’s Take a Closer Look at Each Included Form:
1. ASSIGNMENT OF BENEFITS (AOB) AND BILLING AUTHORIZATION
The AOB and Billing Authorization form is a legal agreement between the client and therapist. It gives the therapist permission to bill the insurance company directly and collect payment.
This agreement includes:
- An explanation for why a diagnosis is necessary when billing insurance
- Information about billing in network and out of network benefits
- Client’s responsibility to disclose all insurance information
- The consequences of not disclosing all insurance information
- Name of person responsible for payment
- Responsibility to pay if the insurance does not cover the service
- Timely filing and the limits of “back billing”
- Space for primary and secondary insurance information
- And more…
2. CREDIT CARD AUTHORIZATION FORM
Credit card authorization gets approval from the client for the therapist to use the client’s credit card to pay for therapy and other fees that may be associated with therapy.
This form collects the card information and explains:
- When, how, and under what circumstance the credit card is charged
- How the client will be notified of the charge
- The security of the credit card number
- That the therapist is not responsible for a credit card company’s potential breech of information
3. INVOICE for SERVICES
The Invoice for Services in a mental health practice is an itemized bill listing charges for each date of service and total amount owed. It is sent to the client who does not use insurance or for a service that is not covered by insurance. Because insurance is not involved, the invoice does not need to include a diagnosis. The invoice can be used as a receipt for services by marking it as paid.
4. SUPERBILL
A superbill is used for clients who pay privately and who get reimbursed by their insurance company. It is an itemized record that lists the services a client received. Because the bill is paid by the insurance company, it includes the client diagnosis, CPT code and modifier, POS, and session fee. The Documentation Wizard Superbill includes a “usual and customary” statement to reduce kickbacks. It’s recommended that the client submits the claims and gets reimbursement directly from the company.
5. INSURANCE OPT-OUT FORM
The Insurance Opt-Out form is a document that allows the client who has insurance to voluntarily choose not to use their insurance to pay for services, even if the therapist is an in-network provider. The client is responsible for paying the therapist’s full fee themselves. The Documentation Wizard Insurance Opt-Out Form explains the limits of retroactive billing should the client change their mind and decide to use their insurance at a later date.
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Financial Management Forms Package – Spanish
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$67
