Pediatric Practice Financial Policy Agreement

Patient Information

Child's Name: _________________________ Date of Birth: //___ Parent/Guardian Name: _________________ Relationship: __________

Financial Responsibility Agreement

Insurance and Coverage

• I understand that I am responsible for knowing my insurance benefits and coverage
• I agree to provide current insurance information and notify the practice of any changes
• I understand that not all services may be covered by my insurance plan

Payment Terms

1. Co-payments are due at the time of service
2. Deductibles and co-insurance amounts are my responsibility
3. Self-pay patients must pay in full at the time of service

Additional Fees

• Missed appointment fee: $50 (if less than 24 hours notice)
• Returned check fee: $35
• Medical record copies: As per state guidelines

Payment Methods

• Cash
• Credit Cards (Visa, MasterCard, American Express)
• Personal Checks
• Health Savings Account (HSA) cards

Authorization

I have read and understand this financial policy. I agree to be bound by its terms and responsible for all charges not covered by insurance.

Signature: _________________________ Date: //___

This agreement remains in effect until revoked in writing.