Payment Pre-authorization Form
22 reviews
24K+
Installs

Use our readymade template to create this Google form. Customize it further using our form builder.

Create your payment pre-authorization form

Assessment form builder
  • navigate_next Use prebuilt template to create a payment pre-authorization form for healthcare services
  • navigate_next Collect patient details, including name, gender, date of birth, contact information, and address
  • navigate_next Capture doctor's name, date of service, description of illness or injury, and amount due
  • navigate_next Generate a summary of the form responses for easy reference and record-keeping

Collect responses from your patients

Patient ID 123456
Patient Name John Doe
Gender Male
Date of Birth 1990-01-01
Phone Number 123-456-7890
Email example@example.com
Address 123 Main St, City, State, ZIP
Doctor's Name Dr. Smith
Date of service 2023-08-08
Place of service Clinic
Description of illness or injury Fever and cough
Amount Due $100
Summary Patient Name: John Doe Gender: Male Date of Birth: 1990-01-01 Phone Number: 123-456-7890 Email: example@example.com Address: 123 Main St, City, State, ZIP Doctor's Name: Dr. Smith Date of service: 2023-08-08 Description of illness or injury: Fever and cough Patient ID: 123456 Place of service: Clinic Amount Due: $100
  • navigate_next Send an email invitation with a secure link for patients to complete the payment pre-authorization form
  • navigate_next Allow patients to save their progress and complete the form at a later time
  • navigate_next Set up an email template and send invitation emails to multiple patients with ease
  • navigate_next Send an email to the patients with a copy of their response when they submit the form

Track patient responses in Google Sheets

Assessment form builder
  • navigate_next Export patient responses to Google Sheets for easy record-keeping
  • navigate_next Create a custom workflow and manage your payment pre-authorization forms efficiently
  • navigate_next Use pre-built reports to easily keep track of patient payment authorizations
  • navigate_next Receive a copy of the response by email when a patient submits the form
  • navigate_next Use data in Google Sheets to integrate with billing systems for seamless payment processing

HIPAA compliance

Patient ID: 123456
Patient Name: John Doe
Gender: Male
Date of Birth:1/1/1990
Phone Number: 123-456-7890
Email: example@example.com
Address:123 Main St, City, State, ZIP
Doctor's Name: Dr. Smith
Date of service:8/8/2023
Place of service: Clinic
Description of illness or injury:Fever and cough
Amount Due: $100
Summary:Patient Name: John Doe
Gender: Male
Date of Birth: 1990-01-01
Phone Number: 123-456-7890
Email: example@example.com
Address: 123 Main St, City, State, ZIP
Doctor's Name: Dr. Smith
Date of service: 2023-08-08
Description of illness or injury: Fever and cough
Patient ID: 123456
Place of service: Clinic
Amount Due: $100
  • navigate_next Create a HIPAA compliant payment pre-authorization form to securely collect patient payment information
  • navigate_next Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
  • navigate_next Mask PHI fields when exporting form responses to Google Sheets and sending them on email
  • navigate_next Pre-populate patient details in payment pre-authorization forms by creating secure prefill links without exposing PHI
  • navigate_next Limit access to patient data only for authorized personnel and minimize risk of data breaches

These reviews are reproduced without modification from Google Workspace Marketplace.

July 27, 2023

5 stars

I am 100% a fan of this company. We use HIPAA compliant Google Forms and needed a way to collect signatures, the industry standard company is TOO expensive. I started using FormEsign and it worked perfectly. It lacked the ability to provide a pdf copy of the form after signature. This company worked with me help their product evolve into something that could benefit all future clients AND the end user. The team was polite, professional, kind, enthusiastic, and willing to make a change. This earned my loyalty. I will sing their praises. Good work, and thank you!

— Royal Bush

July 23, 2023

5 stars

I am not tech savvy. I chose formesign to help create registration links for clients. Vipid has been great in assisting me. He goes above and beyond. My company now has moved from the stone age to modern age through the ability to use this feature. Of the many features I am impressed with, the ability to update a form without needing to regenerate a link is amazing. I often make mistakes and that ability allows me to fix mistakes without needing to change everything. Thank you!!!

— Sol Evans

February 16, 2024

1 stars

Does not work

— Myles Sicuro

October 31, 2023

5 stars

We needed a way to create forms with e-signatures and this app made it very easy. Support is also very quick and always helpful. Cannot recommend enough!

— Chris Henesy

July 12, 2023

5 stars

It very friendly to used. I love it. For my case multiple signature needed. it's supporting

— Senthil Kumar

November 27, 2023

5 stars

Yeah this is good for all

— luqman khan

July 10, 2023

5 stars

We were looking for a way to have a signature option in our form. Formesign addon allowed us to collect signatures for the acknowledgment and consent forms. It was simple and easy to setup. Very useful addon for google forms.

— Joan S

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