Bioidentical Hormone Replacement Therapy (BHRT) Billing Agreement
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This bioidentical hormone replacement therapy billing agreement streamlines the financial onboarding process for patients beginning BHRT programs. The form captures detailed payment preferences, insurance coverage details for hormone therapies, and establishes clear expectations for program fees, consultation costs, pellet insertion procedures, and ongoing monitoring expenses. It includes specific sections for both insurance-based and cash-pay BHRT services.
Designed for integrative medicine clinics, anti-aging centers, and functional medicine practices offering bioidentical hormones, this template addresses the unique billing complexities of hormone replacement programs. The form covers initial consultation fees, lab testing costs, hormone pellet or prescription expenses, follow-up visit charges, and optional concierge program enrollment. It ensures patients understand the financial commitment of BHRT while capturing necessary payment authorization and insurance information.
What's included
- Patient demographic and insurance information
- BHRT program selection and fee schedule
- Initial consultation and assessment fees
- Hormone pellet insertion costs
- Lab testing and monitoring charges
- Prescription or compound medication fees
- Payment method and authorization
- Insurance coverage acknowledgment
- Monthly or annual program fee agreement
- Financial responsibility signature
Who uses this template
- Anti-aging clinics
- Functional medicine practices
- Integrative health centers
- Menopause specialty clinics
- Wellness and longevity centers
All form fields
8 fields across 3 pages. Customize any field after signing up.
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