Financial Policy and Payment Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ Account #: ______________________ Date: ___________________

Financial Policy

Insurance and Coverage

• We participate with most major insurance plans and will submit claims on your behalf
• It is your responsibility to verify that we are in-network with your insurance plan
• You must present a valid insurance card at each visit
• You are responsible for all copayments, deductibles, and non-covered services

Payment Expectations

1. Copayments are due at the time of service
2. Self-pay patients must pay in full at the time of service
3. Deductibles and coinsurance are due upon receipt of statement
4. Non-covered services must be paid at the time of service

Payment Methods

• Cash
• Credit Cards (Visa, MasterCard, Discover, American Express)
• Personal Checks
• Health Savings Account (HSA) cards

Missed Appointments and Late Cancellations

• 24-hour notice is required for appointment cancellations
• A fee of $50 will be charged for missed appointments
• Repeated missed appointments may result in discharge from the practice

Past Due Accounts

• Accounts over 90 days past due may be referred to collections
• Collection fees will be added to the outstanding balance
• Care may be terminated for non-payment

Agreement

I have read and understand the financial policy above. I agree to comply with these terms and accept responsibility for any payment due as described.

Patient/Guardian Signature: _________________________ Date: _____________

Print Name: _________________________

For Office Use Only Received by: _________________________ Date: _____________