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Practice policy example

Financial and payment policy

Illustrative example language for a practice financial policy. Payer contracts and state law constrain fees; adapt and verify.

Download the PDFPDF, 1 page, 4 KB. Free, no sign-up. For clinicians.
Educational example only. This is not legal, medical, or compliance advice, and it is not a ready-to-use legal document. Requirements vary by state, payer, and setting. Adapt anything like this to your own situation and have it reviewed by qualified legal and compliance counsel licensed in your jurisdiction before using it in a practice. You are responsible for compliance with all applicable federal and state laws, including HIPAA. shrinkiatry publishes professional commentary and education, not legal or medical advice.

Current as of July 7, 2026. Laws, payer rules, and billing codes change, so confirm the current requirements for your jurisdiction and setting before you rely on it.

What's inside

Example policy language

Payment is due at the time of service unless arranged otherwise. We accept [payment methods] and may keep a card on file with your consent.

If we're out of network, we can provide a superbill for you to submit to your insurer; reimbursement is not guaranteed.

Cancellation and no-show fees, where allowed, are the patient's responsibility and are not reimbursed by insurance.

Notes for the clinician

  • Disclose fees before the first visit and apply them consistently
  • Confirm payer and state rules on cards on file and no-show fees
  • Provide a Good Faith Estimate when required for uninsured or self-pay patients

About this resource

This template is part of the shrinkiatry resource library, a set of free, clinician-facing references and examples. It's reviewed by Shariq Refai, MD, MBA, FAPA, a board-certified psychiatrist, on a quarterly schedule. Next scheduled review: October 1, 2026. First published July 7, 2026, last reviewed July 7, 2026.

Browse the rest of the resource library, or verify who reviews this site. Spotted something out of date? Email corrections@shrinkiatry.com.

Educational and professional commentary only. shrinkiatry explains the profession of psychiatry. It doesn't provide medical advice, isn't a substitute for evaluation or treatment by a licensed clinician, and reading it doesn't create a doctor-patient relationship.