PAYMENT CONSENT FOR SERVICES
As a condition of your treatment by this office, financial arrangements must be made in advance. Financial District Dental Care depends upon reimbursement from patients for costs incurred in their care, and financial responsibility must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are performed. Patients with dental insurance understand that all dental services rendered are charged directly to the patient, and that the patient is personally responsible for payment of those services. Financial District Dental Care will help prepare the patient’s insurance forms or assist in collecting from insurance companies, and will credit any such collections to the patient's account. Financial District Dental Care, however, cannot render services on the assumption that total dental fees will be paid by the patient’s insurance company. A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previous written financial arrangements have been made in advance.
AGREEMENTS
- I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the treatment diagnosis.
- In consideration for the professional services rendered to me, or at my request, by Financial District Dental Care, I agree to pay the full fees of said services to Financial District Dental Care, at the time said services are rendered, or within five days of billing if credit is extended. I further agree that the fees for said services shall be billed and payable, unless objected to by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition, and I further agree to pay all costs and reasonable attorney fees if suit is instituted hereunder.
- I grant my permission to Raymond C Hahn, DDS, Inc., Financial District Dental Care, or your assignee, to telephone me at home or at my work to discuss matters related to this form.
