US Medical Forms · 中文

财务责任表格

⚠ 这是参考翻译，帮助您了解典型表格内容。这不是官方文件。您的医疗提供者的实际表格可能有所不同——请务必签署提供者自己的版本。

When you receive this form 您在每次新的医疗提供者就诊时都会收到这份表格，通常与患者登记表一起。当您的保险范围发生变化时，也可能在现有提供者处收到此表格。

What to bring or have ready 携带您的保险卡，以便工作人员准确记录您的计划名称和会员ID。提前了解您的自付额和共付额也会有所帮助。

保险福利转让 / Insurance Assignment of Benefits

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Patient Name	患者姓名	Your legal name as it appears on your insurance card.	您的法定姓名，与保险卡上的一致。
Date of Birth	出生日期	Used to match your record with your insurance policy.	用于将您的记录与保险单匹配。
Insurance Carrier / Plan Name	保险公司 / 计划名称	The name of your health insurance company and the specific plan you are enrolled in.	您的健康保险公司名称及您参加的具体计划。
Member ID / Insurance ID Number	会员ID / 保险ID号	The alphanumeric code on your insurance card that identifies your policy. Often labeled 'ID' or 'Member ID'.	保险卡上标识您保单的字母数字代码，通常标记为「ID」或「会员ID」。
Insurance Policyholder Name (if different from patient)	保险持有人姓名（如与患者不同）	If the insurance policy is held by a spouse, parent, or other person, enter that person's name here. Leave blank if you are the policyholder.	如果保险单由配偶、父母或其他人持有，请在此输入该人的姓名。如果您是保险持有人，请留空。
Assignment of Benefits Authorization	福利转让授权	By signing or initialing here, you authorize your insurer to send payment directly to the provider rather than reimbursing you first.	通过在此签名或草签，您授权您的保险公司直接向提供者付款，而不是先向您报销。

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Financial Responsibility Acknowledgment	财务责任确认	You confirm that you are responsible for any amount your insurance does not cover, including deductibles, copayments, coinsurance, and services not covered by your plan.	您确认您负责支付保险不涵盖的任何金额，包括自付额、共付额、共同保险以及计划不承保的服务。
Balance After Insurance Acknowledgment	保险支付后余额确认	You agree that any remaining balance after your insurance has paid its portion will be billed directly to you.	您同意在保险支付其部分后，任何剩余余额将直接向您收取。

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Payment Policy Agreement	付款政策协议	You acknowledge that you have received and understood the provider's payment policies, including billing timelines and any collection practices.	您确认您已收到并了解提供者的付款政策，包括账单时间表和任何催收做法。

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Patient / Authorized Representative Signature	患者 / 授权代表签名	Your signature (or that of a legally authorized representative) confirms you have read and agree to the terms of this form.	您的签名（或法定授权代表的签名）确认您已阅读并同意本表格的条款。
Date Signed	签署日期	The date on which you are signing this form.	您签署本表格的日期。

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Last reviewed: September 2026