Patient Information
Name: _________________________ Date of Birth: _____________
Account #: ______________________ Date: ____________________
Financial Responsibility Agreement
1. Insurance and Payment Policy
- I understand that I am financially responsible for all charges, whether covered by my insurance or not
- I agree to provide current insurance information and notify the practice of any changes
- Co-payments are due at the time of service
- Self-pay patients must pay in full at the time of service
2. Insurance Authorization
- I authorize the release of medical information necessary to process insurance claims
- I authorize direct payment of medical benefits to [Practice Name]
- I understand that my insurance policy is a contract between me and my insurance company
3. Specific Coverage Terms
- Cardiac diagnostic tests require prior authorization
- Some procedures may not be covered by insurance
- Patient responsibility for deductibles cannot be waived
4. Missed Appointments and Late Cancellations
- 24-hour notice is required for appointment cancellation
- A fee of $____ will be charged for missed appointments
- Multiple missed appointments may result in discharge from the practice
5. Payment Terms
- Outstanding balances are due within 30 days
- Payment plans are available upon request and approval
- A 1.5% monthly interest charge applies to balances over 60 days
6. Collection Policy
- Accounts over 90 days past due may be referred to collections
- Patient is responsible for collection agency fees
- Legal fees incurred in collection efforts will be added to the balance
Acknowledgment
I have read and understand this financial policy and agree to its terms.
Signature: _________________________ Date: ________________
Print Name: ________________________