Internal Medicine Practice Financial Policy Agreement

Patient Financial Responsibility

Thank you for choosing [Practice Name] for your medical care. We are committed to providing you with quality healthcare. Please review our financial policy below and sign the agreement.

Insurance and Payment Policies

• We participate with most major insurance plans
• Copayments and deductibles are due at the time of service
• We accept cash, personal checks, and major credit cards
• A $35.00 fee will be charged for returned checks

Patient Responsibilities

1. Provide accurate and complete insurance information
2. Pay all copays and deductibles at time of service
3. Notify us of any changes in insurance coverage
4. Obtain necessary referrals from your primary care physician

Missed Appointments

• 24-hour notice is required for appointment cancellations
• A $50.00 fee may be charged for missed appointments
• Repeated missed appointments may result in discharge from the practice

Outstanding Balances

• Balances are due within 30 days of statement date
• Overdue accounts may be referred to collections
• Payment plans are available upon request

Agreement

I have read and understand the financial policy and agree to comply with its terms. I understand that I am financially responsible for all charges, whether or not paid by insurance.

Patient Name (Print)

Signature

Date