Financial Policy and Payment Agreement

Patient Information

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

Financial Agreement

1. Insurance and Benefits

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

2. Payment Responsibilities

• Co-payments are due at the time of service
• Deductibles and co-insurance amounts are my responsibility
• Self-pay patients must pay in full at the time of service
• A $35.00 fee will be charged for returned checks

3. Surgical Procedures

• A cost estimate will be provided prior to scheduled surgeries
• Pre-payment or payment arrangements must be made before surgery
• I understand that separate bills will be received from:
  • Surgeon
  • Hospital/Surgical Facility
  • Anesthesiologist
  • Pathologist (if applicable)

4. Cancellation Policy

• 48-hour notice is required for appointment cancellations
• $50 fee for missed appointments without proper notice
• $150 fee for missed surgical appointments without 72-hour notice

5. Collections

• Accounts 90 days past due may be referred to collections
• I agree to pay all collection costs and attorney fees if applicable

Acknowledgment

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

Patient/Guardian Signature: _________________ Date: _________

Print Name: ______________________________

Practice Representative: ___________________ Date: _________