Sample Financial Policies and Documents

An effective financial policy sets clear expectations for your practice and patients. Your policy may serve to collect insurance information; outline the responsibilities of guarantors; and detail your practice's billing cycle, after-hours policies and charges, TOS payments, and collections policy. Use this collection of sample policies in conjunction with PCC's practical advice to create or improve your existing financial policy.

• Advice and sample financial policies from PCC
• Patient waiver for non-payment of immunizations from insurance companies (Courtesy of Jill Stoller, M.D., F.A.A.P., Chestnut Ridge Pediatric Associates, P.A.) MS Word PDF OpenOffice
• The AAP has many template letters, including an insurance appeal letter for bundling vision screening and an appeal letter for misinterpreation of modifier -25.
• Letter to insurance company for non-payment of immunizations (Courtesy of Jill Stoller, M.D., F.A.A.P., Chestnut Ridge Pediatric Associates, P.A.) MS Word PDF OpenOffice
• Letter to insurance company regarding inappropriate takebacks PDF
• Immunization cost to reimbursement analysis spreadsheet (Courtesy of Jerry Freed, D.O., South Tulsa Pediatrics, PLLC) MS Excel PDF OpenOffice