1. I understand that payment for dental services rendered is due the day the treatment is performed.
2. I understand that if financial arrangements are made they will be worked out prior to the start of treatment.
3. I understand that account balances of 60 days or more carry a service charge of 1.5 % per month on the unpaid balance.
4. I understand that if collection action is to be taken to collect payment from me I will be responsible for all the costs of such action-collection agency, attorney’s fees and court costs included. The parties agree that in the event that litigation is commenced to enforce this Agreement, that venue for said action shall be in Orange County, Florida.
IF YOU ARE COVERED BY INSURANCE:
5. I understand and agree that I am responsible for payment of all treatment fees on my account. If my insurance company fails to pay within 60 days, I will be responsible for the full amount at that time. I understand that after 60 days all insurance balances will be transferred to account balances due.
6. I understand and agree that the amount estimated to remain unpaid by insurance is to be paid by me at the time of treatment (co-insurance).
7. I understand that this office cannot make a totally accurate estimate of insurance benefits to be paid for me, since it does not have access to all insurance company records.
8. I understand that if this office refiles a claim that was initially denied by my insurance company, there will be a $25 charge to do so.
9. I understand that after the insurance company pays, there could be a balance still remaining to be paid by me and is due in full at that time.
10. I understand that this office does not provide long term financing but does utilize an outside financing agency that can be utilized for patient use.