Urgent Care Financial Policy & Payment Agreement

1. Payment Responsibility

• Payment is expected at the time of service
• We accept cash, credit cards, and approved insurance plans
• Copayments and deductibles are due at check-in
• Self-pay patients must pay in full at time of service

2. Insurance Coverage

• It is your responsibility to:
  • Provide current insurance information
  • Know your coverage benefits
  • Obtain necessary referrals
• We will submit claims to participating insurance carriers
• Non-covered services remain patient responsibility

3. Outstanding Balances

• Balances are due within 30 days of statement date
• Past due accounts may be referred to collections
• $25 fee applies for returned checks
• Payment plans available upon request

4. Missed Appointments

• 24-hour cancellation notice required
• $50 fee for no-shows or late cancellations
• Multiple no-shows may result in discharge from practice

5. Additional Services

• Extra fees apply for:
  • Medical records requests
  • Form completion
  • After-hours services
  • Complex procedures

Patient Acknowledgment

I have read and understand the financial policy above. I agree to comply with these terms and accept responsibility for any payment due.

Patient Name (Print)

Signature

Date