Here is sample of the form
NAME AND ADRESS OF THE PRACTICE
PATIENT FINANCIAL POLICY
SIGNATURE SHEET
I, _________________________ HAVE RECEIVED, READ AND
UNDERSTAND THE FINANCIAL POLICY AND PRIVACY STATEMENT OF ?Dr. Or Practice name?.
I UNDERSTAND THAT I WILL BE RESPONSIBLE FOR ANY BALANCE AFTER INSURANCE HAS PAID FOR A PARTICULAR PROCEDURE OR VISIT. I UNDERSTAND I WILL BE CHARGED A 2% FINANCE CHARGE PER MONTH IN ADDITION TO $50 LATE FEE PER MONTH FOR ANY UNPAID BALANCES.
If any amount owned becomes past due, in addition to such amount, I/we agree to pay all costs incurred by ?Practice Name ?pertaining to collection efforts including, but not limited to (1) court costs, (2) attorney fees, and (3) collection fees whether or not litigated. I further understand that if I default on my payments, all relevant information may be disclosed to credit bureau organizations.
X______________________________________DATE_____________
