Templates & letters
Financial policy template for private-pay therapy practices
A one-page financial policy prevents the awkward conversations. Here's a template written for private-pay pediatric practices — adapt the numbers and have families sign at intake.
PAYMENT. Payment is due at time of service. We keep a card on file and charge it after each visit unless other arrangements are made in writing.
INSURANCE. We are an out-of-network provider. We do not bill insurance directly. Each month we provide an itemized superbill you may submit to your plan for out-of-network reimbursement. Reimbursement depends on your plan and is not guaranteed.
GOOD FAITH ESTIMATE. You are entitled to a written Good Faith Estimate of expected charges. We provide one at intake and update it when your child's plan of care changes.
CANCELLATIONS. We ask for 24 hours' notice. Late cancellations and no-shows are charged [$X / the session fee], which is not reimbursable by insurance and will not appear on superbills.
HSA/FSA. We accept HSA and FSA cards. Superbills serve as your itemized receipt for substantiation.
PAST-DUE ACCOUNTS. Balances over 30 days pause scheduling until resolved. We're always willing to discuss payment plans — please talk to us early.
Signature: ______________________ Date: ____________
Why each clause earns its place
- Card-on-file converts collections from chasing to confirming
- The superbill clause sets OON expectations before the first EOB surprise
- The GFE clause doubles as No Surprises Act compliance
- Excluding no-show fees from superbills is correct — they aren't medical services and payers reject them
FAQ
Can no-show fees go on a superbill?
No. Missed appointments aren't billable medical services and have no CPT code. Charge them separately and keep them off the superbill.
Should the policy mention payment plans?
A sentence inviting early conversation preserves goodwill without committing you to terms. Handle specifics case by case, in writing.
More practice guides
Educational content only — not billing, legal, or tax advice. Verify payer policies and regulations for your state and situation.