Patient payment agreement form

The file attached to this post is a monthly daily ledger. It has a row for each day of the month, with columns for charges, payments by cash, check, electronic or ACH, credit card, and patient financing, total collections, accounts receivable, and the dates and amounts of cash and check deposits.

Office managers and front desk staff can use it to log each day’s numbers and track what patients have paid against what was charged. Reviewing it weekly helps catch payments that were taken but not deposited. If you also need a signed payment agreement with a patient, pair this log with your own written financial policy.