Patient Financial Responsibility
Insurance and Billing
- I understand that I am financially responsible for all charges, whether covered by insurance or not
- I agree to provide current and accurate insurance information
- I authorize the release of any medical information necessary to process insurance claims
- I authorize payment of dental benefits directly to [Practice Name]
Payment Terms
-
Payment Due: Payment is expected at the time of service
-
Accepted Payment Methods:
- Cash
- Credit/Debit Cards (Visa, MasterCard, American Express)
- Personal Checks
- Care Credit
Insurance Policies
- We will submit claims to your insurance carrier as a courtesy
- Estimated co-payments and deductibles are due at time of service
- Any balance remaining after insurance processing is patient responsibility
Missed Appointments and Cancellations
- 48-hour notice is required for appointment cancellation
- A fee of $[Amount] may be charged for missed appointments
- Multiple missed appointments may result in dismissal from the practice
Financial Arrangements
- Payment plans available through Care Credit
- Extended payment arrangements must be approved in advance
- 1.5% monthly interest on balances over 60 days
Agreement
I have read and understand the financial policy above. I agree to comply with all policy terms and accept financial responsibility for dental services provided.
Patient/Guardian Signature
Date
Print Name