Template for Prompt Pay and/or Pre Pay and Eligibility for Medical Indigence and Waiver of Co-Pays

Protect Yourself! Make sure you spell out your policies if you have more than one fee schedule based on variables like prepayment, prompt payment and consideration for client who may not be able to afford your fee. This form includes clauses for prepay, prompt pay and waivers for financial hardships.
Downloadable, editable and attorney reviewed.

Terms and Conditions

By purchasing this form, we are granting you the non-exclusive use of this material. You may not re-sell or otherwise transfer the material to another therapist outside of your own practice. By virtue of submitting payment for the course, you hereby are agreeing to the following:

  1. Digital Product Usage -After purchasing the form, you will be given immediate access to it and will have lifetime access to use it for your own personal use and business use.

    2. Refund Policy- Due to the nature of the form being immediately accessible upon purchasing, no refunds of any fees or other amounts paid by you in connection with the course will be allowed under any circumstances.

    3. Warranties and Liability -Every effort is made to ensure that the form is accurate and fit for the use by purchasers However, we take no responsibility whatsoever for the suitability of the form and provide no warranties as to the function or use of the form, whether express, implied or statutory, including without limitation any warranties of merchantability or fitness for particular purpose. You agree to indemnify the creator against all liabilities, claims, demands, expenses, actions, costs, damages, or loss arising out of any breach of these terms and conditions. The creator shall not be liable to you or any third party for consequential, indirect, special or exemplary damages including but not limited to damages for loss of profits, business or anticipated benefits whether arising under tort, contract, negligence or otherwise whether or not foreseen, reasonably foreseeable or advised of the possibility of such damages.

One of the most common misconceptions that many therapists have is that it is okay to have many fee schedules – one for in network, one for out of network and one for cash paying patients. This template will serve to legitimize and document these scenarios and help you maintain best practice in your back office management. It has been reviewed by an attorney
It is editable so that you can include your practice name etc.


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