Periodontal Practice Financial Policy Agreement

Patient Information

Name: _________________________
Date of Birth: __________________
Account #: ______________________

Financial Agreement Terms

Payment Responsibility

1. I understand that I am financially responsible for all charges, whether covered by insurance or not
2. Payment is expected at the time of service unless prior arrangements have been made
3. For insured patients, I agree to pay all deductibles, co-insurance, and non-covered services

Insurance Policy

• We will submit claims to your insurance carrier as a courtesy
• Insurance coverage is a contract between you and your insurance company
• Pre-treatment estimates are not a guarantee of payment
• Any remaining balance after insurance processing is patient responsibility

Payment Methods

• We accept cash, personal checks, and major credit cards
• Extended payment plans are available through CareCredit®
• A $35.00 fee will be charged for returned checks

Appointment Policy

• 48-hour notice is required for cancellation
• A fee of $75 may be charged for missed appointments or late cancellations
• Multiple missed appointments may result in dismissal from the practice

Collection Policy

• Accounts 90 days past due may be referred to collections
• Patient agrees to pay all collection costs, including attorney fees
• Annual interest of 18% may be charged on overdue accounts

Acknowledgment

I have read and understand this financial policy and agree to its terms.

Signature: _________________________ Date: _____________

Print Name: ________________________

Office Use Only
Staff Initial: ______ Date: ______