As a condition of treatment by this office, I understand financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incured in their care and financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental service performed without prior financial arrangements, must be paid for in cash at the time services are performed.
I understand that dental services furnished to me are charged directly to me and that I am personally responsible for payment of all dental services. If I carry insurance, I understand that this office will help prepare my insurance forms to assist in making collections from insurance companies and will credit such collectionsto my account. However this dental office cannot render services on the assumption that charges will be paid by an insurance company.
Asignemtn of Insurance: I hereby authorize my insurance company to pay directly to my dentist benefits accruing to me under my policy. A service charge of 1 1/2 percent per month (18 percent per annum) (but in no event more than the maximum rate permissible under state law) will be charged on the unpaid principal balance on all accounts not paid within 60 days of treatment date.
I understand that the fee estimate listed foe this dental case can only be extended for a period of six months from the date of the patient's examination. In consideration of the professional services rendered to me, or at my request, by the Doctor and/or his staff, I agree to pay, therefore, the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within the time pf payment thereof. Additionally, I agree that a waiver for any breach of any term or condition hereunder shall not constitute a waiver or any further term or condition. I further agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred including reasonable attorney's and/or collection fees.
I grant my permission to you, or your assignment to telephone me at home or at my work to discuss matters related to theis form.
I have read the above conditions of treatment and agree to their content.