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

I. Payment Timing & Financing

• All patient balances are due immediately after treatment is rendered.
• If I am interested in learning about third-party financing options that offer low monthly payments, I will consult with the front office staff prior to treatment.

II. Past-Due Balances & Fees

• Should a balance accrue on the account a statement will be sent and payment is to be made, in full, by the date on the statement. If payment is not made within 90 days, the account will be subject to be sent to collections. No more than 3 attempts will be made by phone prior to sending an account to collections to retrieve payment.
• A returned check fee of $35.00 will be applied to my account for each check payment returned unpaid by my financial institution.

III. Insurance Claims & Patient Liability

• 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 voluntary courtesy provided by the clinic, not a legal obligation. Ultimately, I am fully responsible for any treatment costs left unpaid by my insurance provider.
• If there is dental insurance on my account, I understand the clinic establishes estimated patient balances based on initial information provided by my carrier. Final treatment payments are subject to the strict terms, conditions, and processing rules of my insurance provider on the actual date of service. Until final payment is received from my insurance provider, my personal portion is an estimate only.
• Estimates do not factor in any insurance maximums or treatment limits that I may have already exhausted at other dental clinics during the current benefit year.
• A submission to my insurance provider will be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment.

IV. Clinical Treatment & Scheduling

• Estimates and treatment plans are based upon observations gained from the initial examination. As with any clinical dental treatment, unforeseen adjustments or complications may arise during care. The clinic will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable.
• All applicable lab charges have been projected and integrated into the total estimate provided.
• The timing or spacing of appointments may need to be modified as needed to accomplish the best clinical result possible. The clinic will make every effort to accommodate my scheduling needs.

V. Consent to Bill Insurance & Release Information

• Authorization to Release Information: I hereby authorize the clinic to release any medical or clinical information, including dental records, radiographs, and diagnoses, necessary to process and determine benefits for my dental insurance claims.
• Assignment of Benefits: I hereby authorize and direct my insurance provider(s) to pay insurance benefits directly to this dental clinic for services rendered. I understand that if my insurance company sends the payment directly to me despite this directive, I am legally obligated to deliver those exact funds to the clinic immediately.

VI. Acknowledgment & Consent

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