Financial Responsibility Assignment and Release
To the extent not paid by the patient’s insurer or other party payor(s) within 30 days from the date of first billing, the undersigned agrees, whether he or she signs as agent or patient, that in consideration of the good to be provided and the services to be rendered to the patient, he or she individually obligates himself or herself to pay upon demand, unless other arrangements are approved in writing by Total Dental Care, Ltd. (“Dentist”), the full outstanding balance for the Dentist’s actual charges for goods and services provided to the patient at the rates or for such fee(s) as are customary for Dentist. The Patient and/or the undersigned agrees that in the event an employee of Dentist, on his or her own initiative or at the request of the Patient and/or undersigned undertakes to determine the availability of insurance coverage directly or on behalf of the Patient or the undersigned, it shall not be a defense to Patient’s and/or the undersigned’s financial obligation hereunder that an employee of Dentist re-communicated to Patient and/or the undersigned information received from the Patient’s medical insurance carrier to the effect that a procedure or course of treatment was or will be covered under the Patient’s policy, notwithstanding that the insurance carrier subsequently denies partial or full payment for such procedure or course of treatment. It is hereby expressly understood and acknowledged by Patient and/or the undersigned that Patient and/or the undersigned are primarily responsible for determining and confirming insurance coverage prior to seeking services.
Beginning on the 30th day from the date service was rendered; all delinquent accounts shall bear interest at the legal rate of eighteen percent (18%) per annum. Should the Account be referred to an attorney or collection agency for collection, the undersigned shall pay all costs of collection, including reasonable attorney fees, collection expenses, costs and court costs which are incurred by the Dentist in enforcing payment after default. There will be a $30.00 charge on all returned checks. It is further hereby agreed that this agreement constitutes the entire agreement of the parties and supersedes and nullifies any prior negotiations, agreements, stipulations or representations unless formalized in writing and directly referencing this agreement. No agent or representative of either party has authority to make, nor is either party relying upon any representation not expressly contained in this Agreement. This Agreement may be amended only by an agreement in writing signed by authorized representatives of both parties. It is also agreed that once a suit is filed as a consequence of the undersigned’s default with respect to any term or condition of this Agreement, only the Dentist’s designated attorney shall have authority to negotiate, compromise or settle any claim arising from such default and that the acceptance of payment by Dentist shall not constitute a waiver of full payment for the amount prayed for by such lawsuit. The undersigned, whether he or she signs as agent or as patient, further authorizes and irrevocably assigns direct payment to Dentist, any insurance benefits otherwise payable to or on behalf of the undersigned for the services rendered. The undersigned understands that he or she is responsible for the entire balance on the account notwithstanding the insurance payments which may have been received for services provided. The undersigned hereby consents for a period not exceeding one year to allow Dentist to release patient’s financial and medical record and/or copies of pertinent medical record information to Dentist’s affiliates and insurance companies or other third party payors. Of course, the above-stated release may be revoked at anytime by Patient, in writing.
NOTICE TO THE UNDERSIGNED: Do not sign this Assignment and Release before you read it and understand it.
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