Financial Policy and Payment Agreement

Patient Information

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

Financial Responsibility

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

Payment Terms

1. Co-payments: Due at the time of service
2. Deductibles: Must be met before insurance coverage applies
3. Self-pay: Payment expected in full at time of service
4. Surgical Procedures: Pre-payment or payment arrangements required prior to surgery

Specific Financial Obligations

Routine Procedures

• Office visits: $_____ co-pay
• Colonoscopy: Estimated patient responsibility $______
• Minor procedures: Payment plan available for amounts over $_____

Surgical Procedures

• Pre-authorization required
• Deposit of $_____ or _____% required before scheduling
• Separate facility and anesthesia fees may apply

Payment Methods

• Cash
• Credit Cards (Visa, MasterCard, American Express)
• Personal Checks
• Healthcare Financing (if approved)

Agreement

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

Signature: _________________________ Date: _______________

Print Name: ________________________

Office Use Only Received by: _____________ Date: _______________