Vascular Surgery Practice Financial Policy Agreement

Patient Information

Name: _________________________
Date of Birth: __________________
Account #: ______________________

Financial Agreement Terms

1. Insurance and Coverage

• I understand that I am financially responsible for all charges, whether covered by my insurance or not
• I agree to present valid insurance information at each visit
• I authorize the release of medical information necessary to process insurance claims
• I assign all insurance benefits directly to [Practice Name]

2. Payment Terms

• Co-payments are due at the time of service
• Self-pay patients must pay in full at the time of service
• Outstanding balances must be paid within 30 days of statement date
• A $35 fee will be charged for returned checks

3. Surgical Procedures

• Pre-authorization requirements must be met before scheduled procedures
• Estimated patient responsibility will be discussed prior to surgery
• A deposit may be required for certain procedures
• Payment arrangements must be made at least 5 days before scheduled surgery

4. Missed Appointments

• 24-hour notice is required for appointment cancellations
• A $50 fee may be charged for missed appointments
• Multiple missed appointments may result in discharge from the practice

5. Financial Assistance

• Payment plans are available upon request and approval
• Financial assistance programs may be available for qualifying patients
• Applications for assistance must be completed thoroughly

Acknowledgment

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

Patient Signature: _________________________
Date: ____________________________________

Practice Representative: ____________________
Date: ____________________________________