Patient Paperwork Financial Policy Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Copays are due at the time of service. Our billing management team is Healthcare Support Technologies, Inc. They bill insurances first; balance billing for whatever insurance does not cover is invoiced to the patient twice on a monthly cycle over 60 days. The phone number, contact, and address for the billing company will be clearly see on invoices. Please communicate financial questions with them. Please address outstanding bills on a timely basis, as we are much more interested in focusing on your healthcare needs than we are on following financial issues, which are viewed more as a necessary evil. If the billing management team has no response from two billing cycles, the account is forwarded to a collections agency which is separate from our practice. That agency charges us a fee of 30% of the balance for accounts with a balance less than $1000, and a fee of 40% fee of the balance for accounts with a balance over $1000. That fee to us will be added to the balance when it is turned over to collections and will be the responsibility of the patient. Patients who habitually allow their accounts to remain unpaid will be discharged from the practice. Name: *FirstLastSignature: * Clear Signature Date: Name: Signature: Date: *Submit Financial Policy Form