Financial Responsibility Form - Lovejoy Dental Center printable pdf download

LOVEJOY DENTAL CENTER

FINANCIAL RESPONSIBILITY FORM

Patient’s Name:__________________________ Date of Birth:___/____/______

Address:__________________________________________________________

Telephone # _______ -__________ Work # _______ -__________

Social Security No: ______-____-______ Employer:_______________________

Dental Insurance Carrier:________________________

ID #_______________ Group #__________________

If Patient is under the age of 18, name of individual who is financially responsible for

Patient:_______________________

If you have dental insurance, we will file the claims for you, as a complimentary service. It is very

important that the correct insurance information is provided at the time of the patient’s appointment. If

this information changes, it is the patient's responsibility to update Lovejoy Dental Center at the earliest

convenience. While we do our best to verify dental benefits prior to your first appointment, this does not

guarantee coverage or payments to Lovejoy Dental Center. We do accept payments from the dental

insurance companies; however, we are not contracted with them. It is a contract between you, your

employer and the insurance company.

If requested, we will provide you with a verbal ESTIMATE of your out of pocket expense for any

treatment planned by the doctor. However, please understand that these are strictly estimates and are not a

guarantee that your insurance company will reimburse us/you according to these estimates.

Please note that any difference in payment from your insurance company and your account balance is

your responsibility. While the filing of insurance claims is a courtesy that we extend to all of our patients,

all charges are your responsibility from the date the services are rendered. If difficulty arises with

payment from the insurance company, we will ask that you contact your carrier to rectify the problem. All

expected insurance balances remaining unpaid after 90 days from the date of service becomes the

immediate responsibility of the patient and/or account holder.

Payment for co-pays and/or deductibles is due at the time services are provided.

Any balance older than 90 days will be subject to interest charges of 1.5% per month, from the date of

service, until the account is paid in full. If a payment has not been received on the account during the 90

days, the account risks being sent to a collection agency or an attorney, additional collection fees will be

applied to any unpaid balance. Any attorney or collections fees incurred due to delinquency in

payment or collection efforts will also be charged to you, including court costs and fees. Any

personal check returned unpaid or with non-sufficient funds (NSF) will incur a $15 NSF check fee and

may also subject you to court costs and attorney fees.

We request a 48 hour cancellation notice for scheduled appointments. A cancellation fee of $50 may be

charged if a 48 hour notice is not given.

I acknowledge having read this Financial Responsibility Form in its entirety and agreed to be bound by all

the terms and conditions herein.

__________________________________

Date:______/_______/________

Signature

Financial Responsibility Form - Lovejoy Dental Center