Geriatric Care Financial Policy Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ Medicare Number: ________________ Social Security #: ____________

Financial Responsibility Agreement

1. Insurance and Medicare Coverage

• I understand that I am responsible for knowing my insurance/Medicare coverage and benefits
• I agree to present current insurance/Medicare cards at each visit
• I will promptly notify the practice of any insurance changes

2. Payment Terms

• Copayments are due at the time of service
• Medicare deductibles must be met before coverage begins
• Secondary insurance billing is provided as a courtesy

3. Additional Services

• Some services may not be covered by Medicare/insurance
• Home visits will be billed according to current Medicare guidelines
• Preventive services may require separate payment

4. Financial Assistance

• Payment plans are available upon request and approval
• Financial counseling services are available
• Medicare savings programs information can be provided

5. Late Cancellation/No-Show Policy

• 24-hour notice is required for appointment cancellation
• A fee of $__ may be charged for late cancellations/no-shows
• Repeated no-shows may result in discharge from practice

Acknowledgment

I have read and understand this financial policy. I agree to comply with these terms and accept financial responsibility for my care.

Signature: _________________________ Date: _____________

Print Name: _________________________ Relationship to Patient: _____________