Sample Financial Agreement Letter

Posted in Agreement Letters

Any document showing a financial obligation between two parties is a financial agreement. A financial agreement letter outlines all of the conditions for such an arrangement that both entities can agree on. This letter can be between any two parties: two companies, two individuals or even a company to a client. Financial agreements are often used by doctor’s offices so that a patient knows upfront what their financial responsibility is beyond insurance.

Format and Content
When writing a financial agreement, the writer should be sure to emphasis all of the important information about payments, including the amount, if applicable, and how the process will work. Exactly what the payment covers should be spelled out in the letter so there is no confusion later. Both parties should have space to sign the agreement. The financial agreement letter format should begin with contact information for both parties involved in the transaction.

The most common use of this kind of letter is between a medical office and their patient. After filling out medical information, the patient will review and sign the financial agreement before seeing the physician. If the patient does not sign the form, the office will not proceed with any services. This agreement is critical for the medical office and might be updated annually. This financial agreement letter sample is between a doctor and her patient and explains all of the fees that will be charged.

August 20, 2013
Dr. Lilly Armstrong
Columbus Family Practice
4215 Ocean Dr. #35
Columbus, OH 08424
1-888-573-2222 ex. 87
Jim Collins
98314 Allen Rd.
Columbus, OH 08423
Dear Mr. Collins,
Please review the financial agreement for our practice. By signing this letter you are agreeing to all the terms in it.
Terms of Financial Agreement with Columbus Family Practice:
I, the patient, understand that I am obligated to provide payment for any medical services received through this office. I understand that while insurance may cover some of my expenses, I will be personally responsible for anything not handled by my insurance.
By signing this letter, I am authorizing my insurance to cover any expenses attributed to Columbus Family Practice.
I agree to cover any co-pay at the time of my visit. I will pay any bill received within 30 days. I will provide a credit card at my first visit and agree that any failure to pay after 60 days will result in a non-refundable late fee charged to this card.
Columbus Family Practice will provide all bills within two weeks of any visit. Itemized bills can be requested. These bills will only include my personal costs, not what was billed to the insurance company. The insurance company can provide more detailed information.
I understand that it is my responsibility to understand the coverage and limitations of my insurance.
By signing this letter, I am certifying that all of my billing information is correct including my address, phone number and email. I will provide a copy of my insurance card and license when returning this letter to the front desk.
I have read and agree to the terms above.
Columbus Family Practice
Date ________________________________
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