As validated by my signature on the bottom of this form, I understand and agree that: 

All patient balances are due when treatment is rendered. 

Should a balance accrue on my account - a statement will be sent and payment is to be made, in full, by the date on the statement. If payment is still not paid within 60 days, balance is subject to an 18% annual finance charge (1.5% per month) and may be applied to the entire account balance. In the event any unpaid balance shall be referred to attorney for collection, I understand that an attorney's fee of 33.33% will be added to the past due balance to help cover the additional costs of collection.

A returned check fee may also be applied and must be payable from you for each check payment returned to us by your bank. 

Dental insurance is a contract between the patient, their employer (if applicable) and the insurance provider. Submitting claims for payment to the insurance provider is a courtesy provided by the dentist, not an obligation. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider. 

If there is dental insurance on the account, I understand that the office has estimated the patient balance based on the information I have provided. Final payment is subject to the terms and conditions of my insurance provider on the date of service. As such, no patient payment is final until payment is received from my insurance provider. 

Estimates and treatment plans are based upon information gained from the examination. This is a preliminary estimate only and any lab charges (if applicable) have not been estimated and included total.

In office estimates may not take into consideration any treatment that was billed toward my insurance but used at other dental clinics. 

I may choose to have the office send an inquiry to my insurance provider (Pre-D or Prior Auth) to determine a more accurate final payment. However, it is an estimate only. Predeterminations from my insurance provider(s) are NOT a guarantee of payment. Final determinations will be made when claims are received by my insurance carrier.

As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. The office will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments may need to be modified as needed to accomplish the best result possible. 

I have read, understand and agree to the above financial policy for payment of professional fees. I understand that I am ultimately responsible for all fees for services rendered to me and/or my family.