Orthopedic Practice Financial Policy Agreement

Patient Information

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

Financial Responsibility Agreement

1. Insurance and 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

2. Payment Terms

• Co-payments are due at the time of service
• Self-pay patients must pay in full at the time of service
• Deductibles and co-insurance amounts are due within 30 days of billing

3. Surgical Procedures

• Pre-authorization requirements must be met before scheduling
• A deposit may be required for certain procedures
• Payment arrangements must be made prior to surgery

4. Orthopedic Equipment and Supplies

• Payment for braces, splints, and other medical equipment is due at time of service
• Insurance coverage for equipment varies; patient responsible for uncovered items

5. Missed Appointments

• 24-hour notice required for cancellations
• $50 fee for missed appointments without proper notice
• Multiple missed appointments may result in discharge from practice

Authorization

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

Signature: _________________________ Date: _______________

Print Name: ________________________