Medical Financial Responsibility Form Template for India

1. Third-Party Guarantor: Used when someone other than the patient assumes financial responsibility

2. International Patient Provisions: Additional terms for international patients, including currency considerations

3. Government Scheme Coverage: Specific terms for patients covered under government healthcare schemes like Ayushman Bharat

4. Installment Payment Plan: Terms for patients requiring structured payment plans

5. Charity Care Program: Information about financial assistance programs and eligibility

6. Special Treatment Costs: For specialized procedures or treatments with significant cost implications

7. Digital Payment Terms: Special provisions for electronic payment methods and online transactions

1. Schedule A: Fee Schedule: Detailed breakdown of standard charges for common procedures and services

2. Schedule B: Insurance Information: List of accepted insurance providers and coverage requirements

3. Schedule C: Payment Plan Options: Available payment plan structures and terms

4. Appendix 1: Patient Rights: Detailed explanation of patient rights regarding billing and financial matters

5. Appendix 2: Documentation Requirements: List of required documents for insurance claims and financial assistance

6. Appendix 3: Contact Information: Important contact details for billing department, insurance liaison, and financial counselors