JOB SKILL 13-6
Complete a Financial Agreement
Fill in a financial agreement with a schedule of payments.
JOB SKILL 13-6 Complete a Financial Agreement Name Date Score Performance Objective Task: Fill in a financial agreement with a schedule of payments. Conditions: Need: Computer with Internet connection Blank Form 54 (Financial Agreement) Calculator Pen or pencil Refer to: Textbook Figure 13-11 for a visual example Textbook Procedure 13-3 for step-by-step directions Standards: Complete all steps listed in this skill in minutes with a minimum score of (Time element and accuracy criteria may be given by instructor.) Time: Start: Completed: Total: minutes Scoring: One point for each step performed satisfactorily unless otherwise listed or weighted by instructor. Directions with Performance Evaluation Checklist Mr. Biederman has received an itemization of all charges that are now overdue. He has no insurance and has agreed to a payment plan; there will be no financial charge. 1st Attempt 2nd Attempt 3rd Attempt Gather materials (equipment and supplies) listed under Conditions. /2 /2 /2 1. Enter patient's name, Alan Biederman, and telephone number, (555) 486-9093, on the financial agreement form. /9 /9 /9 2. Mr. Biederman has incurred $3000 for medical services with Dr. Gerald Practon and has agreed to pay $600 as a down payment. Determine the unpaid balance and fill in Sections 1 through 9 on the agreement form. 78 /8 /8 3. Mr. Biederman agrees to pay $200 on the first of every month starting August 1 (current year). Calculate the amount and number of monthly payments and fill in the lower section of the form. 4. Have Mr. Biederman sign and date the form; it is July 1 (current year). /3 /3 /3 5. On the Schedule of Payment, fill in the total amount owed, the down payment (DP), and the balance owed in the top right portion of the form. /24 /24 /24 6. Complete the Schedule of Payment by filling in all dates and the amount of each installment payment. 7. Present the form to Dr. Practon for his signature. Complete within specified time. /50 /50 /50 Total points earned (To obtain a percentage score, divide the total points earned by the number of points possible.) Date Due SCHEDULE OF PAYMENT Amount of Date Amount Installment Paid Paid Total Amount Balance Owed No. D.P. 1 2 3 4 4 5 5 6 7 8 9 10 FINANCIAL AGREEMENT For PROFESSIONAL SERVICES rendered or to be rendered to: Daytime Patient Phone Parent if patient is a minor 1. Cash price for services $ 2. Cash down payment.......... $ 3. Charges covered by insurance service plan. $ 4. Unpaid balance of cash price................... $ 5. Amount financed (the amount of credit provided to you).............. $ 6. FINANCE CHARGE (the dollar amount the credit will cost you). ... $ 7. ANNUAL PERCENTAGE RATE (the cost of credit as a year- ly rate) % 8. Total of payments (5 + 6 above. The amount you will have paid when you have made all scheduled payments) ................... $ 9. Total sales price (1 + 6 above-Sum of cash price, financing charge and any other amounts financed by the creditor, not part of the finance charge) $ You have the right at anytime to pay the unpaid balance due under this agreement without penalty. You have the right at this time to receive an itemization of the amount financed. I want an itemization I do not want an itemization Total of payments (# 8 above) is payable to Dr. in monthly installments of $ each and installments of $ _each. The first installment being payable on 20 and subsequent installments on the same day of each consecutive month until paid in full. NOTICE TO PATIENT Do not sign this agreement if it contains any blank spaces. You are entitled to an exact copy of any agreement you sign. You have the right at any time to pay the unpaid balance due under this agreement The patient (parent or guardian) agrees to be and is fully responsible for total payment of ser- vices performed in this office including any amounts not covered by any health insurance or prepayment program the responsible party may have. See your contract documents for any additional information about nonpayment, default, any required prepayment in full before the scheduled date and prepayment refunds and penalties. Signature of patient or one parent if patient is a minor: Date: Doctor's Signature Form 1826 - 1962 11 12 13 14 15 16 17 18 19 20 21 22 23 JOB SKILL 13-6 Complete a Financial Agreement Name Date Score Performance Objective Task: Fill in a financial agreement with a schedule of payments. Conditions: Need: Computer with Internet connection Blank Form 54 (Financial Agreement) Calculator Pen or pencil Refer to: Textbook Figure 13-11 for a visual example Textbook Procedure 13-3 for step-by-step directions Standards: Complete all steps listed in this skill in minutes with a minimum score of (Time element and accuracy criteria may be given by instructor.) Time: Start: Completed: Total: minutes Scoring: One point for each step performed satisfactorily unless otherwise listed or weighted by instructor. Directions with Performance Evaluation Checklist Mr. Biederman has received an itemization of all charges that are now overdue. He has no insurance and has agreed to a payment plan; there will be no financial charge. 1st Attempt 2nd Attempt 3rd Attempt Gather materials (equipment and supplies) listed under Conditions. /2 /2 /2 1. Enter patient's name, Alan Biederman, and telephone number, (555) 486-9093, on the financial agreement form. /9 /9 /9 2. Mr. Biederman has incurred $3000 for medical services with Dr. Gerald Practon and has agreed to pay $600 as a down payment. Determine the unpaid balance and fill in Sections 1 through 9 on the agreement form. 78 /8 /8 3. Mr. Biederman agrees to pay $200 on the first of every month starting August 1 (current year). Calculate the amount and number of monthly payments and fill in the lower section of the form. 4. Have Mr. Biederman sign and date the form; it is July 1 (current year). /3 /3 /3 5. On the Schedule of Payment, fill in the total amount owed, the down payment (DP), and the balance owed in the top right portion of the form. /24 /24 /24 6. Complete the Schedule of Payment by filling in all dates and the amount of each installment payment. 7. Present the form to Dr. Practon for his signature. Complete within specified time. /50 /50 /50 Total points earned (To obtain a percentage score, divide the total points earned by the number of points possible.) Date Due SCHEDULE OF PAYMENT Amount of Date Amount Installment Paid Paid Total Amount Balance Owed No. D.P. 1 2 3 4 4 5 5 6 7 8 9 10 FINANCIAL AGREEMENT For PROFESSIONAL SERVICES rendered or to be rendered to: Daytime Patient Phone Parent if patient is a minor 1. Cash price for services $ 2. Cash down payment.......... $ 3. Charges covered by insurance service plan. $ 4. Unpaid balance of cash price................... $ 5. Amount financed (the amount of credit provided to you).............. $ 6. FINANCE CHARGE (the dollar amount the credit will cost you). ... $ 7. ANNUAL PERCENTAGE RATE (the cost of credit as a year- ly rate) % 8. Total of payments (5 + 6 above. The amount you will have paid when you have made all scheduled payments) ................... $ 9. Total sales price (1 + 6 above-Sum of cash price, financing charge and any other amounts financed by the creditor, not part of the finance charge) $ You have the right at anytime to pay the unpaid balance due under this agreement without penalty. You have the right at this time to receive an itemization of the amount financed. I want an itemization I do not want an itemization Total of payments (# 8 above) is payable to Dr. in monthly installments of $ each and installments of $ _each. The first installment being payable on 20 and subsequent installments on the same day of each consecutive month until paid in full. NOTICE TO PATIENT Do not sign this agreement if it contains any blank spaces. You are entitled to an exact copy of any agreement you sign. You have the right at any time to pay the unpaid balance due under this agreement The patient (parent or guardian) agrees to be and is fully responsible for total payment of ser- vices performed in this office including any amounts not covered by any health insurance or prepayment program the responsible party may have. See your contract documents for any additional information about nonpayment, default, any required prepayment in full before the scheduled date and prepayment refunds and penalties. Signature of patient or one parent if patient is a minor: Date: Doctor's Signature Form 1826 - 1962 11 12 13 14 15 16 17 18 19 20 21 22 23
