Dental Office Financial Agreement Form printable pdf download

DENTAL OFFICE FINANCIAL AGREEMENT

Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that

payment of your bill is considered part of your treatment. The following is a statement of our financial policy which we require that

you read and sign prior to any treatment.

General:

Understand that regardless of any insurance status, you are responsible for the balance due on your account. You are responsible for

any and all professional services rendered. This includes but is not limited to: dental fees, surgical procedures, tests, office

procedures, medications and also any other services not directly provided by the dentist.

MISSED APPOINTMENTS:

Unless we receive notice of cancellation 48 hours in advance, you will be charged $35.00. Please help us service you better by

keeping scheduled appointments.

INSURANCE

Please remember your insurance policy is a contract between you and your insurance company. We are not a party to that contract.

As a courtesy to you, our office provides certain services, including a pre-treatment estimate which we send to the insurance company

at your request. It is physically impossible for us to have knowledge and keep track of every aspect of your insurance. It is up to you

to contact your insurance company and inquire as to what benefits your employer has purchased for you. If you have any

questions concerning the pre-treatment estimate and/or fees for service, it is your responsibility to have these answered prior to

treatment to minimize any confusion on your behalf.

Please be aware some or perhaps all of the services provided may or may not be covered by your insurance policy. Any balance is

your responsibility whether or not your insurance company pays any portion.

PAYMENT:

FULL PAYMENT is due at the time of service. If insurance benefits apply, ESTIMATED PATIENT CO-PAYMENTS and

DEDUCTIBLES are due at the time of service, unless other arrangements are made.

Please indicate below the form of payment you wish to choose.

( )

Cash or check

( )

Visa, MasterCard, Discover

( )

If you qualify, a monthly payment plan is available for your convenience.

Unpaid balance over 30 days old will be subject to monthly interest of 1.5% (APR 18%). If payment is delinquent, the patient

will be responsible for payment of collection, attorney’s fees, and court costs associated with the recovery of the monies due on

the account.

The parties agree that in the event of a dispute over any payment or fee due to Dr. Fogel by the undersigned, the Circuit Court of

Kankakee County shall have exclusive jurisdiction and venue for any litigation filed by either party.

By signing this Financial Agreement, I understand and agree that you are authorized to check my credit and employment

history.

I have read, understand and agree to the terms and conditions of this Financial Agreement.

Signature: ______________________________________________

Date:___________________________________

Dental Office Financial Agreement Form