Financial Agreement

FINANCIAL RESPONSIBILITIES

As a courtesy to you, we will send the necessary documents to your insurance and third party payers for you to receive any benefits you may have. If you opt to take care of billing your third party payers or insurance companies on your own, we will gladly support you in making sure you have all of the information you may need to do so.

I understand that any insurance co-pays are due at the time of treatment. I agree that I am fully responsible for the total payment of all procedures performed in this office – this includes any treatment that is not a benefit of any dental insurance that I may have. I understand that all services are to be paid in full within sixty (60) days of the date of service, regardless of whether or not my insurance benefits have been received.

We are committed to providing the highest quality dental care available to all of our patients. In order to have these services, we offer these options for payment: Cash/ Check/Credit card/Care credit

If you pay with a check or cash the full payment is due at the time of your appointment.

Third Party Payment Plan: CARE CREDIT This is the only payment plan we offer. Please let one of the team members know if you have any questions or need additional details.

MISSED APPOINTMENTS

Appointment times are reserved especially for you. If for any reason you should need to change your appointment, there will be no charge, provided you give us 48-hour notice. Please help us serve you better by keeping your scheduled appointments.

If you decide that you need to cancel your appointment within the 48 hour office policy, or you do not show for your appointment, we reserve the right to charge a fee of $50 per hour or the deposit amount used to reserve your appointment.

We are here to assist you in any way possible. Please make your questions and concerns known to our team… Our goal is to ensure that you have an outstanding experience!

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

On File Form of Payment

I authorize Radiant Dental of Bedford to keep my credit card and signature on file and to charge my card for treatment as it is rendered or for our cancellation policy. This amount will not be charged without my acknowledgement.

I assign my insurance benefits to the provider listed above. I understand that this form is valid for one year, unless I cancel the authorizations through written notice to the healthcare provider.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.