Gastroenterology Practice Financial Policy Agreement

Patient Information

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

Payment Policy

Thank you for choosing our practice. We are committed to providing you with quality gastroenterological care. Please read and sign this financial policy agreement.

Insurance and Payment Responsibility

• We participate with most major insurance plans
• You are responsible for:
  • Providing accurate insurance information
  • Payment of copayments at time of service
  • Deductibles and non-covered services
  • Obtaining necessary referrals

Payment Methods

• We accept:
  • Cash
  • Personal checks
  • Major credit cards
  • Health savings account (HSA) cards

Procedure Scheduling

• A deposit may be required for certain procedures
• Insurance benefits will be verified prior to scheduling
• Cost estimates will be provided upon request

Missed Appointments

• 24-hour notice is required for cancellations
• $50 fee for missed office visits
• $100 fee for missed procedures

Past Due Accounts

• Accounts over 90 days past due may be referred to collections
• Payment plans are available upon request
• 1.5% monthly interest on unpaid balances

Agreement

I have read and understand the financial policy and agree to its terms.

Signature: _________________________ Date: _______________

Print Name: ________________________