Financial Agreement

Financial Agreement

You will be asked to make a payment for services on the day provided unless other arrangements have been made in advance. You will be responsible for any financial obligations incurred in connection with dental treatment rendered on my behalf or on behalf of my child.

Financial Arrangements Office Policy for Surgical Treatment

Payment Option 1: Cash (or check) in (Paid in full)
Payment Option 2: Visa, MasterCard, Discover Card (Paid in full)
Payment Option 3: Care-Credit (Paid in full)
Payment Option 4: Postdated checks (Half down, other half paid over 90 days)

You information is safe! The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately.

Primary Dental Insurance Information:

Name of Insured:

Relationship to patient:

Employer:

Address:

Insurance Company:

Address:

Telephone Number:

Group #:

Insured’s ID #:

SSN:

For e.g. AAA-GG-SSSS

DOB:

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Secondary Dental Insurance Information: (if applicable)

Name of Insured:

Relationship to patient:

Employer:

Address:

Insurance Company:

Address:

Telephone Number:

Group #:

Insured’s ID #:

SSN:

For e.g. AAA-GG-SSSS

DOB:

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Please provide our office with a copy of all insurance cards. If insurance information is not correct, it will delay payment and estimates towards your treatment. Accuracy is greatly appreciated and helps us provide you with timely answers on you coverage levels. Insurance coverage is predetermined prior to treatment, to the best of our ability, unless otherwise discussed. Your insurance coverage is a contract between you and the company. We are happy to work closely with you in attempting to obtain full benefits for our provided services. However, you are ultimately responsible for your balance.

Patient or Legal Guardian Signature:

Clear

Date

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