Price: $15.00
Format: Editable PDF | 1 Page | Instant DownloadDescription:
Keep your financial expectations clear from the start.
This simple, signature-ready form ensures clients understand and agree to your practice’s payment, cancellation, and card-on-file policies. It’s clean, professional, and designed to protect your revenue while maintaining transparency.Includes:
Financial responsibility acknowledgment
Card-on-file and billing consent language
Missed appointment and cancellation acknowledgment
Signature and date fields for compliance documentation
Fillable, editable PDF format with GBBS branding
Perfect for:
Therapists, psychiatrists, and group practices wanting a clear, compliant way to document client agreement to payment terms.
* Created by Golden Bee Billing Services, LLC — experts in behavioral health billing, compliance, and operational design.
Taxes included in price.
Payment Policy Acknowledgment (2025 Edition)
© 2025 Golden Bee Billing Services, LLC
All rights reserved. This document is an original work created by Golden Bee Billing Services, LLC and may not be copied, resold, or distributed without written permission.This template is intended for informational and administrative use only. It does not constitute legal advice and should be reviewed or customized to fit your individual practice policies and state regulations before use.
Licensing Your purchase includes a single-use commercial license for use within one private practice. You may print, fill, and digitally store the form for client use within your practice, but redistribution, resale, or reproduction for others is not permitted.
Pricing Note All prices listed in The Hive Shop include applicable taxes. No additional fees will be added at checkout.