Estimated Patient Responsibility

Confirmation of Insurance Benefits

Health Insurance policies are an agreement between you and your insurance company. You are personally responsible for all services in our office. All unpaid charges will be billed directly to you, the patient. We accept assignment of benefits after your insurance has been verified. Your insurance company will send payment directly to our billing department. We will promptly credit all received payments from your insurance company. We are providing your insurance benefits as a courtesy. It is your responsibility to contact your insurance for your benefits.

Patient ID

SAMPLE-001

Patient name

Sample Patient

Insurance name

Aetna (Training)

Date of verification

07/27/2026

Details of Benefits and Estimated Patient Responsibility (EPR) calculations

Type	Deductible	Deductible remaining	Out of pocket	OOP remaining	Co-pay	Co-ins	Estimated patient responsibility
Individual	$3,000.00	$580.00	$6,000.00	$3,580.00	$0.00	20%	$90.00
Family	$4,400.00	$180.00	$8,800.00	$7,459.53	$0.00	20%	$90.00

Notes

Since you have not yet met your family deductible, you will owe $90.00 for the first 2 visits after which you will be charged only your coinsurance of 20% on the allowed amount which will be approximately $18.00 for each subsequent visit until the out-of-pocket has been met.

Visits allowed 30

Visits remaining 13

My signature below states that I have read, and have been informed of my insurance benefits by my insurance company. I understand that insurance verification is NOT a guarantee of payment. I am aware of my financial responsibility to Sample Therapy Clinic. Sample Therapy Clinic will bill my insurance as a courtesy, I am aware that if my insurance company does not pay in a timely manner, it will be my responsibility to follow up with my insurance company and/or I will be responsible for the amount owed to Sample Therapy Clinic. I understand and agree to these terms and conditions.

Office policy on payment

It is our policy to require payment of all office charges at the time they are given, unless prior arrangements have been specifically made. A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing any information related to this debt to a consumer credit reporting agency. If a person knowingly violates that provision, the debt shall be void and unenforceable.

Patient / Guardian signature

Patient / Guardian print name

Date

Definitions

Deductible: The amount that a patient must pay for covered expenses before the insurance company begins to pay its share.
Out of pocket: The amount that a patient pays for medical expenses that are not covered by a health insurance plan.
Co-payment (COPAY): A fixed amount that a patient pays for a specific healthcare service at the time of the visit.
Co-insurance: Percentage of medical costs a patient pays after meeting their deductible, with the rest covered by their insurance.
Est. patient resp.: Amount patients are expected to pay for healthcare services after insurance coverage. It includes deductibles, co-payments, co-insurance, and uncovered services.

FINANCIAL RESPONSIBILITY SAMPLE-001 SAMPLE PATIENT 07-27-2026 17:00:35.PDF

Sample data