Skip Navigation LinksCollecting-Payment-from-Patients

Collecting Payment from Patients


Payment Related Letters
Template letters notifying families about a practice's financial policies, outstanding balances, questions about bills, co-payments, etc. 

Credit Card on File (CCOF)
Sample Authorization Forms and Templates
These sample documents are provided as a reference for practices developing their own materials and ma​y be adapted to local needs. Please note, these documents do not represent offi​cial American Academy of Pediatrics (AAP) policy or guidelines and the AAP is not responsible for their use. You should consult an attorney who is knowledgeable about the laws of the jurisdiction in which you practice before creating or using any legal documents.

  • CCOF policy: Includes a sample CCOF policy from a pediatric office to use as a template
  • CCOF authorization forms: Includes sample authorization forms that pediatric practices may use to tailor to their own office
  • CCOF notice to patients: Includes sample letter that pediatric practices may use as a template​
​ ​​​​​​​​​