Cardiac Surgery Financial Policy & Payment Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Financial Agreement

1. Insurance Coverage

• I understand that I am financially responsible for all charges, whether covered by my insurance or not
• I agree to provide current and accurate insurance information
• I authorize the release of medical information necessary to process insurance claims

2. Pre-Authorization Requirements

• I understand that pre-authorization for cardiac surgery is required by most insurance plans
• I acknowledge that obtaining pre-authorization does not guarantee payment by insurance
• I agree to assist in obtaining necessary pre-authorizations if required

3. Estimated Costs and Patient Responsibility

• Estimated surgical costs: $_____________
• Estimated patient responsibility: $_____________
• Deposit required: $_____________

4. Payment Terms

• A deposit of __% is required prior to scheduling surgery
• Payment plans are available for qualifying patients
• All copayments and deductibles are due prior to surgery

5. Cancellation Policy

• 72-hour notice is required for surgery cancellation
• Late cancellations may incur a fee of $_____________

Acknowledgment

I have read and understand this financial policy. I agree to comply with these terms and accept financial responsibility for services provided.

Patient/Guardian Signature: _________________ Date: _________

Practice Representative: ___________________ Date: _________