Use our readymade template to create this Google form. Customize it further using our form builder.
Create your payment pre-authorization form
- Use prebuilt template to create a payment pre-authorization form for healthcare services
- Collect patient details, including name, gender, date of birth, contact information, and address
- Capture doctor's name, date of service, description of illness or injury, and amount due
- 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 |
| 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 |
- Send an email invitation with a secure link for patients to complete the payment pre-authorization form
- Allow patients to save their progress and complete the form at a later time
- Set up an email template and send invitation emails to multiple patients with ease
- Send an email to the patients with a copy of their response when they submit the form
Track patient responses in Google Sheets
- Export patient responses to Google Sheets for easy record-keeping
- Create a custom workflow and manage your payment pre-authorization forms efficiently
- Use pre-built reports to easily keep track of patient payment authorizations
- Receive a copy of the response by email when a patient submits the form
- 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 |
- Create a HIPAA compliant payment pre-authorization form to securely collect patient payment information
- Mark fields as Protected Health Information to secure sensitive data and limit access to PHI
- Mask PHI fields when exporting form responses to Google Sheets and sending them on email
- Pre-populate patient details in payment pre-authorization forms by creating secure prefill links without exposing PHI
- 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 23, 2023
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!!!
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February 16, 2024
Does not work
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October 31, 2023
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July 12, 2023
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November 27, 2023
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July 10, 2023
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