Free standard financial policy — professional wording your business can adapt in minutes. Available in English, Español and 中文. Swap the [bracketed] parts, or let KwickPhone fill in your business name automatically.
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Financial Policy Agreement
Payment is due at the time of service. As a courtesy, [Business Name] files insurance claims on my behalf; I understand insurance estimates are NOT a guarantee of payment, and I am responsible for deductibles, co-payments and any amount my plan does not cover. Treatment-plan prices are valid for [90] days. Balances over [30] days may accrue a late charge where permitted by law; accounts over [90] days may be sent to collections. Returned payments incur a $[amount] fee.
Acuerdo de Política Financiera
El pago vence al momento del servicio. Como cortesía, [Nombre del Negocio] presenta reclamos al seguro en mi nombre; entiendo que los estimados del seguro NO son garantía de pago, y soy responsable de deducibles, copagos y cualquier monto que mi plan no cubra. Los precios del plan de tratamiento son válidos por [90] días. Los saldos de más de [30] días pueden generar recargo donde la ley lo permita; las cuentas de más de [90] días pueden enviarse a cobranza. Los pagos devueltos generan un cargo de $[monto].
⚖️ These templates are general starting points, not legal advice. Rules differ by state and by business — have your attorney review your final wording before you use it.
State-by-state differences
TX — Texas: informed-consent disclosures follow the Texas Medical Disclosure Panel lists; document consent for procedures on List A in writing.
CA — California: patients may request records within 5 working days (inspection); CMIA privacy rules apply on top of federal privacy requirements.
FL — Florida: dental records must be kept at least 4 years (Board rule); patient-abandonment rules require 30 days' coverage after ending care.
NY — New York: patient records must be retained 6 years (adults) or until a minor turns 22; surprise-bill disclosures apply to out-of-network care.
IL — Illinois: dental records generally retained 10 years; patients get copies within 30 days of a written request (fees capped by statute).
NJ — New Jersey: patient records kept at least 7 years from the last entry; provide copies within 30 days of request.
GA — Georgia: retain records 10 years from the last entry (minors longer); Board of Dentistry rules govern transfers when a practice closes.
CO — Colorado: dental board rules require records for 7 years after the last treatment (or age 25 for minors, whichever is later).
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