Medical Bill Assistance - Become a Client Today!

Become a Freedom Negotiators Client

Let's Get Started!

Our sign-up process is simple. Fill out the below form and pay the processing fee.

We are so confident in our ability to reduce your medical bill that we offer a Money Back Guarantee!

If we are unable to save you more than your processing fee - we will refund you 100% of the processing fee!

Bill Amount	Processing Fee
Less than $15,000	$150
$15,000 or More	$300

If you have any questions, please call us at (888) 973-2838.

Become A Client

"*" indicates required fields

Step 1 of 4

25%

Name*

First Last

Street*

City*

State*

ZipCode*

Email*

Phone*

Consent

By submitting this form and checking this box, I am agreeing to receive text messages from Crown Administrators and business partners. I provide my signature expressly consenting to recurring contact from Crown Administrators or its business partners at the number I provided regarding products or services via live, automated or prerecorded telephone call, text message, or email. I understand that my telephone company may impose charges on me for these contacts, and I am not required to enter into this agreement as a condition of purchasing property, goods, or services. I understand that I can revoke this consent at any time. Terms & conditions/privacy policy apply (https://freedomnegotiators.com/privacy-policy/).

Consent to communictions

HIPAA PRIVACY

Please provide the following information for our HIPAA Privacy Authorization Form. This form is required before we can speak with your healthcare provider(s).

What is your relationship to the patient?*

Examples: Self, Mother, Father, Guardian

HIPAA In Force Until*

The HIPAA agreement will be in force (effective) until the date or event you specify. Which would you prefer?

Choose an end date

Specify and event

HIPAA In Force Until Date*

Your HIPAA Authorization will be in effect until this date

MM slash DD slash YYYY

HIPAA In Force Until event*

Authorized Provider 1*

Please provide name, address, and phone number of provider related to your medical bill.

Authorized Provider 2

Please provide name, address, and phone number of provider related to your medical bill.

Effective Period*

Specify the authorization for release of information covers the period of healthcare services by date range or an event.

all past, present, and future periods

Date Range

Effective Start Date

MM slash DD slash YYYY

Effective End Date

MM slash DD slash YYYY

Extent of Authorization*

I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse)

I authorize the release of my complete health records, with the exception of the following information

HIPAA Release Exclusions

Mental health records

Alcohol/drug abuse treatment

Communicable diseases (including HIV & AIDS)

Other (please specify)

HIPAA Authorization Other

FAMILY INFORMATION

Patient Information

Patient First Name*

Patient Last Name*

Patient Birthdate*

MM slash DD slash YYYY

Asset and Tax Information

Income Tax Filing Status*

Number of Dependents*

Please enter a number less than or equal to 10.

Member's Occupation*

Spouse's Occupation

Prior Year Gross Household Income*

Your household's gross annual income. Click HERE for the definition of Gross Income.

Prior Year Adjusted Household Income*

Your household's adjusted annual income. Click HERE for the definition of Adjusted Income.

How much can you commit?*

How much can you commit to settling your balance?

Hidden

PlaceHolder

Other Information

Motor Vehicle Accident?*

Work Accident?*

Other Forms of Coverage?*

Hidden

PlaceHolder

Carrier

Carrier Phone Number

Group Number

Member/Subscriber ID

Brief Description of the Incident/Notes

Please provide any information that might help our negotiations team.

Almost Done!!

When you click the Next button we will present your Freedom Negotiators Client Agreement for your electronic signature.

After you have completed the client agreement, you will be prompted to pay your processing fee using PayPal. You can use an existing PayPal account or a credit card.

We will also send you an email with the subject Freedom Negotiators Email Confirmation. Please click the button in the email to confirm you have requested our assistance. Confirmation helps email delivery to your e-mailbox.

Phone

This field is for validation purposes and should be left unchanged.

Become A Client

"*" indicates required fields

Step 1 of 4

25%

Name*

First Last

Street*

City*

State*

ZipCode*

Email*

Phone*

Consent

Consent to communictions

HIPAA PRIVACY

Please provide the following information for our HIPAA Privacy Authorization Form. This form is required before we can speak with your healthcare provider(s).

What is your relationship to the patient?*

Examples: Self, Mother, Father, Guardian

HIPAA In Force Until*

The HIPAA agreement will be in force (effective) until the date or event you specify. Which would you prefer?

Choose an end date

Specify and event

HIPAA In Force Until Date*

Your HIPAA Authorization will be in effect until this date

MM slash DD slash YYYY

HIPAA In Force Until event*

Authorized Provider 1*

Please provide name, address, and phone number of provider related to your medical bill.

Authorized Provider 2

Please provide name, address, and phone number of provider related to your medical bill.

Effective Period*

Specify the authorization for release of information covers the period of healthcare services by date range or an event.

all past, present, and future periods

Date Range

Effective Start Date

MM slash DD slash YYYY

Effective End Date

MM slash DD slash YYYY

Extent of Authorization*

I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse)

I authorize the release of my complete health records, with the exception of the following information

HIPAA Release Exclusions

Mental health records

Alcohol/drug abuse treatment

Communicable diseases (including HIV & AIDS)

Other (please specify)

HIPAA Authorization Other

FAMILY INFORMATION

Patient Information

Patient First Name*

Patient Last Name*

Patient Birthdate*

MM slash DD slash YYYY

Asset and Tax Information

Income Tax Filing Status*

Number of Dependents*

Please enter a number less than or equal to 10.

Member's Occupation*

Spouse's Occupation

Prior Year Gross Household Income*

Your household's gross annual income. Click HERE for the definition of Gross Income.

Prior Year Adjusted Household Income*

Your household's adjusted annual income. Click HERE for the definition of Adjusted Income.

How much can you commit?*

How much can you commit to settling your balance?

Hidden

PlaceHolder

Other Information

Motor Vehicle Accident?*

Work Accident?*

Other Forms of Coverage?*

Hidden

PlaceHolder

Carrier

Carrier Phone Number

Group Number

Member/Subscriber ID

Brief Description of the Incident/Notes

Please provide any information that might help our negotiations team.

Almost Done!!

When you click the Next button we will present your Freedom Negotiators Client Agreement for your electronic signature.

After you have completed the client agreement, you will be prompted to pay your processing fee using PayPal. You can use an existing PayPal account or a credit card.

Phone

This field is for validation purposes and should be left unchanged.