Endocrinology Practice Financial Policy Agreement

Patient Information

Name: _________________________
Date of Birth: __________________
Account Number: ________________

Financial Responsibility Agreement

Insurance and Coverage

• I understand that I am responsible for knowing my insurance benefits and whether services rendered at [Practice Name] are covered.
• I agree to provide current and accurate insurance information and present my insurance card at each visit.
• I understand that I am responsible for any charges not covered by my insurance plan.

Payment Terms

1. Co-payments: Due at the time of service
2. Deductibles: Any unmet deductible is due at time of service
3. Self-pay Patients: Payment in full is expected at time of service
4. Laboratory Services: Additional charges may apply for lab work

Specialty Care and Procedures

• Hormone testing and specialized endocrine procedures may incur additional costs
• Prior authorization requirements must be met for certain treatments
• Continuous glucose monitoring (CGM) and insulin pump supplies may require separate coverage verification

Missed Appointments and Late Cancellations

• 24-hour notice is required for appointment cancellation
• $50 fee may be charged for missed appointments or late cancellations
• Multiple missed appointments may result in discharge from the practice

Payment Methods

• Cash
• Credit/Debit Cards
• Personal Checks
• Health Savings Accounts (HSA)
• Flexible Spending Accounts (FSA)

Agreement

I have read and understand the financial policy of [Practice Name] and agree to comply with its terms. I understand that I am financially responsible for all charges whether or not paid by my insurance.

Signature: _______________________
Date: ___________________________

A copy of this agreement will be provided upon request.