Payment Arrangement Form - Smiles On Elston

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PAYMENT ARRANGEMENT FORM
PATIENT NAME
(“pati ent”)
PAYMENT AGREEMENT
I agree that I am responsible for all services rendered to the Pati ent and that payment is due and payable
to Smiles on Elston at the ti me services are rendered and that health, dental and accident insurance policies are an arrangement
between my insurance carrier and me. I agree to pay all deducti bles and co-pays at the ti me of service (if I have dual insurance
coverage, my co-pay or deducti ble will be based on the primary coverage). I understand that while Smiles on Elston will fi le claims with
my insurance company on my behalf, I remain responsible to Smiles on Elston for what is not paid by my insurance company. I also
understand that if Smiles on Elston cannot verify insurance benefi ts eligibility for me prior to treatment that I will pay in full for the
services at the ti me they are rendered. I understand that Smiles on Elston may charge:
1) a late fee if payment on my account is not received by the due date;
2) an amount equal to $35.00, but not to exceed the maximum amount permitt ed by law for each returned check, and
3) a fee for each appointment that is missed/canceled without at least 24 hours advance noti ce.
I agree to the extent permitt ed by law, that if my account balance is referred to any agency or att orney(s) for collecti on purposes, to
pay reasonable att orney’s fees and any expenses or costs relati ng to the collecti on proceeding, including court costs. l understand that
if treatment or care is suspended at any ti me by the pati ent, all fees for professional services rendered will be immediately due and
payable. l authorize payment directly to Smiles on Elston.
RESPONSIBLE PARTY:
Full Name ________________________________________________ DOB _________________ SS# _________________________
Street Address ______________________________________ City _________________________ State _________ Zip ___________
Home Phone _______________________________________ Work Phone _______________________________________________
Employer Name ______________________________________________________________________________________________
INSURANCE INFORMATION:
PRIMARY INSURANCE:
Primary Insurance Name ______________________ Address ____________________________ Phone Number ________________
Name of Insured _____________________________ Relati onship __________ID Number ____________ Group Number_________
SECONDARY INSURANCE:
Secondary Insurance Name ____________________ Address ____________________________ Phone Number ________________
Name of Insured _____________________________ Relati onship __________ID Number ____________ Group Number_________
I acknowledge having received a copy of Smiles on Elston’s Noti ce of Privacy Practi ces. I agree that a photocopy of this
authorizati on is as valid as the original.
Locati on where this agreement was signed: Smiles on Elston, 5780 N. Elston Ave., Chicago, IL 60646
Signature of Responsible Party ______________________________________________ Date ______________________
(to be signed even if Pati ent is also the Responsible Party)

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