Patient financial agreement template 2026

1. Click ‘Get Form’ to open the patient financial responsibility agreement in the editor.
2. Begin by entering your name and date of birth in the designated fields at the top of the form. This information is crucial for identifying your account.
3. Fill in your account number, ensuring it matches the records held by Integrated Medical Services, Inc. (IMS).
4. Review the insurance information section carefully. Make sure to provide up-to-date insurance details and verify that all current insurance cards are on file.
5. In the health plan deductibles, co-payments, and coinsurance section, acknowledge your understanding of any payments required before receiving services.
6. For non-covered services, ensure you understand your financial responsibilities regarding any services not covered by your insurance.
7. Complete the referral section if applicable, confirming that a valid referral is on file before your appointment.
8. If you are self-paying or have no insurance, indicate this clearly and be prepared for estimated payment collection prior to service.
9. Finally, read through all policies outlined in the document. Sign and date at the bottom to confirm your agreement with IMS's terms.

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