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Financial Policy Sample Documents

Here are some sample documents to help you set clear guidelines with your patients and develop a consistent system for following up on overdue payments. For more information about the purpose, contents, and success of creating a financial policy, see our article in the Resource Library, Writing a Financial Policy.

Example Financial Policy Patient Handout

A financial policy is a formal set of procedures that your practice follows with regards to collecting money. This should be a written statement that is given to all patients and is posted (at least in brief form) at your check-out counter. This policy should be supported by a set of procedures for staff to follow included in your Office Policies and Procedures Manual.

Use this sample Financial Policy Patient Handout to customize your own practice-specific policies. Download the Microsoft Word or Open Office Document. 

Example Billing and Collection Letter Series

Your practice should develop a set of letters and phone call scripts to be used when following-up on late payments. You need to determine at what points to suggest a payment plan, to
discharge a patient, and to turn over accounts to a collection agency. The series of letters and phone calls should reflect this progression and should include specific information about balances due, recent payments and, in the case of budget plans, minimum monthly payments and deadlines. The task of sending the letters and making phone calls should be assigned to a specific person or persons, such as the office or billing manager. 


Below is a sample set of procedures your office can follow regarding delinquent payments. We have also included Sample Letters that you can tailor to fit the particular needs of your practice and your patients.

Step 1: Collect time of service payments or make sure the patient leaves with a bill.

Step 2: Send statements on a regular basis. Consider cycle billing to decrease the time between a patients visit and receipt of the bill.

Step 3: After 30 days, send Letter #1. (Some offices prefer to start with a phone call and follow-up with a letter.) Download Sample Letter #1 in Microsoft Word or Open Office Format.

Step 4: After 60 days, send Letter #2. Download Sample Letter #2 in Microsoft Word or Open Office Format.

Step 5: Contact patient by phone 7 days after date of Letter #2.

Step 6: If you do not receive the first installment payment, send Letter #3 no more than 10 days after the first due date. Download Sample Letter #3 in Microsoft Word or Open Office Format.

Step 7: After 20 days, a Discharge Letter should be sent by certified mail and by regular mail, and the account should be turned over to a collection agency. Before discharging a patient, check with the doctor to make sure that the patient does not have a significant medical condition. Offer to provide emergency care for a short period of time or whatever period is required by state law. Download Sample Discharge Letter in Microsoft Word or Open Office Format.

Additional Resources

Writing a Financial Policy

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Dischargeletter.doc104.5 KB
Dischargeletter.odt68.86 KB
SampleFinancialPolicy.doc109.5 KB
SampleFinancialPolicy.odt79.52 KB
Sampleletter1.doc104 KB
Sampleletter1.odt65.83 KB
Sampleletter2.doc104.5 KB
Sampleletter2.odt67.02 KB
Sampleletter3.doc104 KB
Sampleletter3.odt63.15 KB