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Financial Agreement Form

  • PLEASE TAKE A MOMENT TO READ AND SIGN

    PATIENTS WITH NO INSURANCE: Payment is due at the time of treatment.

    RETURNED CHECK FEE: $30

    PATIENTS USING DENTAL INSURANCE: We ask you pay the known portion of the charges on the day of treatment. After thirty days (30) you will be responsible for payment. In consideration for the professional services rendered now and in the future, the undersigned hereby agrees to pay eighteen percent (18%) interest per annum on all balances which are unpaid sixty days (60) after the services are rendered; plus attorney’s fees which are hereby stipulated to be thirty three and one third percent (33 1/3%) of such outstanding balance whether suit is filed or not; plus court costs. If the undersigned fails to promptly pay for the services rendered, the undersigned authorizes the release by or to any credit reporting agencies of personal credit information on the undersigned and further agrees to pay all costs of obtaining such credit information and / or locating the undersigned, as may be necessary.

    The undersigned understands that the provider as a courtesy bills dental and medical insurance claims if the patient promptly furnishes the provider with all correct insurance information. The undersigned is fully responsible for all sums due whether or not insurance coverage is available.

    In the absence of prompt payment, the undersigned understands that medical, personal and financial records concerning these professional services will be released to the provider’s attorney for collection. The attorney will act as the provider’s “Business Associate” in compliance with the federal “Health Insurance Probability and Accountability Act”.

  • Date Responsible Party

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