Oncology Practice Financial Policy Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ________________

Financial Agreement Terms

1. Insurance and Coverage

• I understand that I am financially responsible for all charges not covered by my insurance
• I agree to provide current insurance information and notify the practice of any changes
• I authorize the release of medical information necessary to process insurance claims

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

3. Treatment Costs

• I understand that cancer treatment may involve substantial costs
• Prior authorization does not guarantee payment by insurance
• The practice will provide cost estimates upon request

4. Payment Options

• Cash, check, or credit card payments accepted
• Payment plans available upon approval
• Financial assistance programs may be available for qualifying patients

5. Missed Appointments

• 24-hour cancellation notice required
• Missed appointment fee: $__________

Acknowledgment

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

Patient Signature: _________________________ Date: _____________

Print Name: _________________________

Witness: _________________________ Date: _____________