Financial Agreement Form

Financial Agreement Form

Form is used as a financial agreement for the dental industry. Gathering financial information of the interested one. Create a HIPAA Compliant Financial Agreement Form today. Form Preview
  • Financial Agreement

  • Financial Policy Acknowledgment

    The following information is to inform you of our financial policy. If, at any time, you have questions regarding this policy, please do not hesitate to ask any member of our dental team.

    We are committed to providing you with the highest qualify of care. Our fees are a reflection of the quality of care we provided. We continue our commitment by offering a variety of financial options to enable you to receive the dental care you need. We accept cash, check, VISA, MasterCard, American Express, and Discover. We have also partnered with a third-party company to offer the flexibility of no interest as well as extended payment options.

    **Check Policy: If your check is returned for any reason, there will be a returned check fee of $35 PLUS the processing fee associated with our financial institution. Upon notice of a returned check to our office, your balance must be paid in full by utilizing either cash or credit card.**

    We will communicate all recommended treatment options and associated fees prior to the start of treatment. Payment is expected at the time of treatment. A delinquent account impedes our ability to provide you with quality dental care that you deserve. It is our policy that the guardian who accompanies a child to our office for treatment is responsible for payment of all services rendered.

    We are committed to respecting your time and ask that you make every effort to keep the appointment time reserved exclusive for you. We understand there may be times when you are unable to keep you schedule appointment, however, we do ask that you provide our office with a 24 hour notice should you need to reschedule.

    As a courtesy to our patients with dental insurance benefits, we will submit and provide any necessary information to assist you in receiving your dental benefits. We require that any applicable deductibles and estimated patient portion be paid at the time treatment is rendered. We do accept assignment of benefits (meaning that in most cases the dental insurance check can be paid to our practice) to help reduce your immediate out-of-pocket expense. We can not guarantee payment from an insurance company and any remaining balance left after insurance payment is patient's responsibility.

    Please contact your insurance carrier prior to your visit to obtain essential information which will accurately reflect your coverage.

    **If you have a direct reimbursement policy, payment in full is expected on the day of service and your dental plan will reimburse you.**

    • It is your responsibility to understand the type of dental insurance you have (i.e. Traditional, PPO, or DMO), and the benefits selected by you and/or your employer.
    • You (not the insurance company) are responsible for the fee of services rendered.

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