Sample Patient Payment Plan Agreement

You should tailor your policy to your practice and answer the following: Here`s a simple form that you can download and use in your doctor`s office to set up a payment plan with patients. When payment is due (for example. B the date of service, unless other agreements have been concluded in advance); Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan with which we do business, full payment is expected at each visit. If you are insured by a plan that we do business with but do not have a current insurance card, full payment is required for each visit until we can verify your coverage. . . .