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Patient Payment Agreement Form

Patient Payment Agreement Form Template for New Zealand

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Patient Payment Agreement Form

"I need a straightforward Patient Payment Agreement Form for my small dental practice in Auckland, with standard payment terms and a cancellation policy, to be implemented from January 2025."

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The Patient Payment Agreement Form is a essential document for healthcare providers in New Zealand to establish clear financial arrangements with their patients. This agreement is designed for use when initiating a new patient relationship or updating existing payment arrangements, ensuring transparency in financial obligations and compliance with New Zealand healthcare regulations. The document covers payment terms, fee structures, insurance arrangements, and ACC claims processes, while adhering to the requirements of the Health and Disability Commissioner Act 1994, Privacy Act 2020, and other relevant legislation. It's particularly important for private practices, specialist clinics, and other healthcare providers who need to document payment arrangements with their patients.
Suggested Sections

1. Parties: Identifies the healthcare provider and the patient (including full legal names, addresses, and contact details)

2. Background: Brief context explaining the purpose of the agreement for healthcare services payment

3. Definitions: Defines key terms used throughout the agreement including 'Services', 'Fees', 'Payment Terms', etc.

4. Services Covered: Outlines the healthcare services that are subject to this payment agreement

5. Fee Structure: Details the fees for services, including standard consultation rates and additional charges

6. Payment Terms: Specifies payment timing, accepted payment methods, and any immediate payment requirements

7. Patient Acknowledgment: Patient's confirmation of understanding and agreement to the payment terms

8. Default and Late Payments: Consequences of missed payments and late payment procedures

9. Privacy and Information Handling: How patient's financial and personal information will be handled and protected

10. Term and Termination: Duration of the agreement and conditions for termination

11. Execution: Signature blocks for all parties with date fields

Optional Sections

1. Third-Party Payments: Include when insurance companies or other third parties are involved in payment

2. Payment Plan Details: Include when offering installment payments or special payment arrangements

3. Guarantor Details: Include when someone other than the patient is guaranteeing payment

4. ACC Claims: Include for services that may be covered by ACC (Accident Compensation Corporation)

5. Cancellation Policy: Include when specific cancellation fees or policies apply

6. Special Discounts: Include when offering community service cards, student, or other discount arrangements

7. Direct Debit Authorization: Include when automatic payments are being set up

Suggested Schedules

1. Schedule 1 - Fee Schedule: Detailed breakdown of all possible fees and charges for services

2. Schedule 2 - Payment Plan Terms: Specific details of payment plan options including installment amounts and dates

3. Schedule 3 - Direct Debit Terms: Terms and conditions for direct debit arrangements if applicable

4. Appendix A - Privacy Policy: Detailed privacy policy regarding handling of patient financial information

5. Appendix B - Cancellation Policy: Detailed cancellation and refund policies

Authors

Alex Denne

Head of Growth (Open Source Law) @ ¶¶Òõ¶ÌÊÓƵ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co
Relevant legal definitions



































Clauses

























Relevant Industries

Healthcare

Medical Services

Dental Services

Allied Health

Mental Health Services

Physiotherapy

Private Practice

Public Health

Community Health

Specialist Medical Services

Relevant Teams

Administration

Finance

Front Desk

Operations

Legal

Compliance

Patient Services

Accounts Receivable

Practice Management

Clinical Operations

Relevant Roles

Practice Manager

Healthcare Administrator

Medical Office Manager

Financial Controller

Accounts Receivable Officer

Medical Receptionist

Healthcare Provider

Clinical Director

Business Manager

Compliance Officer

Legal Counsel

Operations Manager

Industries








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Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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