As a condition of treatment by this office, patients are expected to pay their balance at the time of service or to make financial arrangements in advance. The practice depends upon the reimbursement from patients for the costs incurred in their care, and financial responsibility on the part of each patient must be determined before treatment.
As a courtesy, for those patients who carry dental insurance, the practice will send claims to the patient's insurance company first. We will then send a statement for any remaining balance to the responsible party. This office cannot render services on the assumption that our charge will be paid by an insurance company. We ask that all patients update us immediately with any changes to insurance coverage.
A late fee or service charge of 1.5% per month (18% annum) on the unpaid balance or $10.00 minimum per month may be charged on all accounts exceeding 60 days unless previously written financial arrangements are satisfied.
In consideration for the professional services rendered to me, or at my request, by the Doctor, 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 five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition, and I further agree to pay all costs and reasonable attorney fees if suit shall be instituted hereunder.