Consent for Services and Financial Policy As a condition of treatment by this office, financial arrangements must be made in advance. Financial responsibility on the part of each patient must be determined before treatment. Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 30 days unless previously written financial arrangements are satisfied. I understand that any fee estimate for this dental care can only be extended for a period of three months from the date of the patient examination. In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within 14 days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. 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 be instituted hereunder. I grant my permission to you or your assignee, to telephone, email, or text message me to discuss this statement or my treatment.Patient or Guardian SignatureDateInsurance Authorization:I authorize:My insurance company to pay the dentist insurance benefits rendered. If your insurance provides us with an EOB (explanation of benefits) you will be required to pay that balance on the date of your appointment (with any form of payment). We require a valid credit card on file so that we can charge your card any outstanding balances after your insurance payments. You must also inform us if your credit card information or expiration date changes.I authorize the use of this electronic signature on all insurance submissions.I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.I (Name)authorize Dr. Boisson to keep my signature on file and to issue a credit or debit memo to my credit card account (VISA / MASTERCARD/ AMERICAN EXPRESS) for any over or under payment once my insurance portion is received. I will be notified by phone, email, mail or text of any charge or credit in excess of $300.00. A receipt for this transaction will be mailed with a paid statement.(Please note we cannot accept Visa Debit to keep on file)NameDateCredit Card Number:EXP. DATECVVSignature: Send Message
