Financial Policy CASH: Payment in full is due at the time services are rendered. We accept cash, checks and credit cards. lfyou wish to conveti to insurance billing, please refer to the insurance section below and notify this office immediately. INSURANCE: We submit insurance claims on your behalf. Co-payments are due at the time of each visit. If your co-payment is not made, you will be billed. We must have a signed consent from you with the assignment of payments to this office in order to file claims for you. All PATIENTS: You are ultimately responsible for all charges regardless of any dental coverage, and this office cannot accept responsibility for collecting your insurance claim or for negotiating settlement on disputed claims. Upon discharge from this office, all charges are due and payable within 60 days. A 1 .5% monthly finance charge is added to all amounts after 60 days. This represents an annual percentage rate of 18%. All accounts, on reaching 90 days past due, are subject to submission to an outside collection agency if satisfactory payment arrangements have not been made with the billing office. You will be charged $40.00 for a returned check from your bank for nonsufficient funds. CANCELLED APPOINTMENTS: This office requires a 24-hr notice if you are unable to keep your scheduled appointment. If we do not receive a 24-hr notice, you will be charged a fee of $40.00. If you have any questions or need to make special arrangements for payment, please notify the billing office immediately. I have read and fully understand and agree to the above information. Patient or Guardian NameDate MM slash DD slash YYYY I do not agree to the above policy and will pay in full for my services in advance of my dental treatment. Patient or Guardian NameSignatureDate MM slash DD slash YYYY
