Insurance Consent Policy

and assign directly to Dr. Hallaian all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

If my account is more than 30 days delinquent I will be charged 1.5% monthly until the balance is
satisfied.

I understand that if Dr. Hallaian refers my account to a collection agency my account will be increased by 25%. In the event my account is referred to an attorney, I will pay lawyer fees of 25% of the total unpaid balance plus court costs.

In the event I fail to pay any services that are due and my account is referred to a collection agency/attorney for non-payment, you may report my failure to pay to a credit bureau and request a copy of my consumer credit report to aid in the collection of this obligation.

The above-named dentist may use my healthcare information and may disclose such information to the above-named Insurance Companies and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

I acknowledge I have received and read a copy of this office's Notice of Privacy Practices.

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.