This is an agreement between Drs. Kenneth M. Groves, and Amy S. Fender, as creditors, and thePatient/Debtor named on this form.
In this agreement the words “you,” “your,” and “yours” means the Patient/Debtor. The word “account” means the account that has been established in your name to which charges are made and payments credited. The words “we”, “us,” and “our” refer to Drs. Kenneth M. Groves, and Amy S. Fender.
By executing this agreement, you are agreeing to pay for all services that are received.
Monthly Statement: If you have a balance on your account that is not due from insurance only, we will send you a monthly statement. It will show separately the previous balance, any new charges to theaccount, the finance charges, if any, and any payments or credits applied to your account during the month. Any charges shown in the patient portion column are due upon receiving the statement.
Payment Options If You Have No Insurance:
- You may choose to pay by cash, check, or credit card (Visa/MasterCard/Discover} on the day that the treatment is rendered.
- On treatment involving laboratory fees (crowns, bridges, dentures, etc.), you must pay 50% of the procedure fee on the preparation day and the balance when the treatment is finished (unless other arrangements are made prior in writing).
- On extensive treatment, you may prefer to secure a bank, credit union, or third-party financing for the entire amount and make payments to the lending institution.
Payment Options If You Have Insurance:
- You choose to pay your deductible of $ and any co-payments at the time services arerendered by cash, check, or credit card (Visa/MasterCard/Discover), We can only estimate yourco-payment at the time of service.
- On extensive treatment (crowns, bridges, dentures, etc.), you must pay 50% of your co-payment on the preparation or start date, and the balance when the treatment is finished (unless other arrangements are made prior in writing).
Payments: Unless other arrangements are approved by us in writing, the balance on your statement issue and payable when the statement is received, and is past due if not paid by the end of the month issued. You are responsible for informing our office of changes of address.
Charges to Account: We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid in full at the time of service.
Contracted Insurance: If we are contracted with your insurance company, we must follow our contract and their requirements. If you have a co-pay or deductible, you must pay that at the time of service.
Because this is an insurance requirement, we cannot bill you for these, or waive them. The insurance company makes the final determination of your eligibility. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to do so may result in a lower payment from the insurance company. If you go over the maximum amount allowed per year by your insurance company, it is your responsibility to pay that amount.
Non-Contracted Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges not covered by insurance. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to do so may result in a lower payment from the insurance company. If you go over the maximum amount allowed per year by your insurance company, it is your responsibility to pay that amount.
Credit History: We have the option to refuse to grant credit to you. We also have the option to report account status to any credit-reporting agency such as a credit bureau in cases of delinquent accounts
Returned Checks: There is a fee (currently $20) for any checks returned by the bank.
Missed Appointment Fee: Patients who do not show up on time for an appointment, or cancel with less than 24 hours' notice will be charged a $45.00 fee. This fee must be paid before a new appointment is scheduled. Patients with three missed appointments will be asked to transfer their records to another doctor,
Past Due Accounts: If your account becomes past due, we will take necessary steps to collect this debt including placing a blemish on your credit history or placing a legal judgment against you. If we have to refer your account to a collection agency, you agree to pay all collection costs incurred. If your collection balance is referred to a lawyer, you agree to pay all lawyers' fees that we incur plus court costs. In case of suit, you agree the venue will be in the county of Saginaw.
Divorce: In the case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decreer requires the other parent to pay all or part of the treatment costs, it is the authorizing responsibility to collect from the other parent.
Transferring Of Records: You will need to request in writing and pay a copying fee of $20 if you want to have copies of your records sent to another doctor or organization. You authorize us to include all relevant information, including your payment history.
Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.
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.