DOCUMENT OVERVIEW: This document may be used internally by medical staff to help
determine the financial viability of a patient. Effective patient financial viability assessment can
facilitate enhanced medical billing.
__________________________________________ ___________________________
Name of patient
Balance due
____________
Date of last patient visit
Reason for nonpayment or for lack of contact:
❏ Patient is deceased ❏ Patient refused to pay
❏ Post returned ❏ Payment is late or not paid in ___ months
❏ Patient’s telephone is disconnected or number changed
❏ Patient moved out-of-state
❏ Other:
Telephone contact: ❏ Yes ❏ No
Dates of telephone contact: __________________________________________________
Discussed a payment plan with patient: ❏ Yes ❏ No Highlights of discussion:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Which collection letters were sent? ___________________________________________
Have all payments from insurance company been received? ❏ Yes ❏ No
Amount outstanding ______________ How old is bill? ______________
Staff recommendation:
❏ Write off ❏ Settle for partial payment ❏ Send to collection
Physician’s recommendation:
❏ Write off ❏ Settle for partial payment ❏ Send to collection
Terminate care? ❏ Yes ❏ No
__________________________________________ ________________________
Signature of physician Date