As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon payment from the patients for the cost incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at time of service. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental service. This office will help prepare the insurance claims and help assist in making collections form the insurance company. This office does not render treatment of the assumption that our charges will be paid by our patient’s insurance company.
At time of treatment, I would like to take care of my balance in the following manner:
1. I will pay by cash or check at time of service.
2. I will pay by credit card at time of service.
3. I am interested in the in-house service plan contract
4. I would like to apply for an extended payment plan through Care Credit.
In consideration for the professional services rendered to me, I agree to pay for the value of the services rendered to me, at the time said services are rendered, if a balance is outstanding once we receive your insurance payment, you must remit the balance within five days of the statement. I agree to pay all costs and reasonable court and or attorney fees if suit be instituted hereunder.
A Finance charge of 11/2 % per month (18% per annum) on the unpaid balance will be charged in all accounts exceeding 60 days.