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1. Third-Party Billing Authorization: Optional section for cases where billing may be directed to third parties other than primary insurance

2. Payment Plan Provisions: Include when offering payment plan options for outstanding balances

3. Specific Procedure Costs: Detailed breakdown of costs for specific procedures, used when the waiver relates to specific known treatments

4. Provincial Health Insurance Opt-Out: Required only when services are provided outside the provincial health insurance system

5. Language Acknowledgment: Required in provinces with language laws (e.g., Quebec) or when dealing with patients requiring translation

6. Medical Emergency Provisions: Special terms applying to emergency medical situations where standard billing procedures may not apply

1. Schedule A - Fee Schedule: Detailed listing of standard fees and charges for medical services

2. Schedule B - Insurance Coverage Details: Specific information about insurance coverage, limitations, and exclusions

3. Schedule C - Payment Terms: Detailed payment terms, including payment methods and late payment policies

4. Appendix 1 - Patient Rights and Responsibilities: Comprehensive explanation of patient rights and responsibilities regarding billing

5. Appendix 2 - Privacy Policy: Details of how billing and personal health information will be handled and protected

6. Appendix 3 - Provincial Health Insurance Information: Information about provincial health coverage and limitations specific to the jurisdiction