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 27, 2023
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July 23, 2023
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February 16, 2024
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October 31, 2023
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