A financial policy is the practice's money rules, stated plainly, signed by the patient before the first visit. Done well, it converts the three most uncomfortable conversations in a front office — copay collection, unpaid balances, and missed-appointment fees — into "as you agreed when you signed up."
Section 1: Insurance participation
State that filing claims is a courtesy, that patients are responsible for confirming you're in-network, and that copays, coinsurance, and deductibles are due at time of service. That last clause isn't optional politeness — most payer contracts require you to collect them.
Section 2: Referrals and authorizations
Make it the patient's responsibility to obtain plan-required referrals before the visit, and say what happens without one: reschedule, or proceed as self-pay. Practices that skip this section eat the denials.
Section 3: Self-pay terms
Publish that a fee schedule is available on request, and reference the Good Faith Estimate requirement under the No Surprises Act for uninsured and self-pay patients. Payment due at service unless a written plan exists.
Section 4: Balances and collections
- Statement terms: balances due within a stated number of days (30 is typical)
- What triggers collections referral (commonly 90+ days), and any fees added — only to the extent your state permits
- Returned-payment fee amount
Section 5: Missed appointments
Reference your cancellation/no-show policy and its fee, and state that missed-appointment fees are not billable to insurance — patients often assume otherwise.
Section 6: Administrative fees
Forms completion (FMLA, disability), medical-records copies per state fee limits, and anything else you charge for. Surprises here generate more bad reviews than the fees themselves.
The acknowledgment block
End with a signature block where the patient agrees to financial responsibility, authorizes release of information for claims, and assigns benefits to the practice. Without the signature, the policy is a wish.
Skip the drafting entirely
The Private Practice Intake & Policy Bundle includes all five patient-facing documents — intake packet, financial policy, HIPAA notice, cancellation policy, and telehealth consent — professionally formatted in editable Word files. $99, instant download.
See the bundle →Two mistakes to avoid
Vague numbers. "A fee may apply" invites argument; "$50" ends it. Policies you won't enforce. If you waive everything, the document trains patients that the rules are decorative. Write the policy you'll actually apply, and give staff a defined exception path instead of ad-hoc mercy.