Credit/Debit Policy

I understand it is the policy of Michelle Deutch, D.D.S. to secure my credit or debit
card information at the time of my visit. The office acknowledges that we must
comply with the provisions of the U.S. law.

If, after a claim has been submitted to my insurance carrier: 1) the claim is denied
for any reason: OR 2) there is a patient liability (I.E. Deductible, Co-insurance, etc.)
the office will send a statement notifying me of the balance. If this amount is not
paid within 60 days, then my credit or debit card will be charged for the entire
balance owed for treatment of services to me.

I understand my insurance company will also provide notification of these charges
with an explanation of benefits. In the event this amount exceeds $250.00, the
office will provide a courtesy call to my phone number.

I understand that in the event my credit or debit card has been charged for
treatment or services, and then my insurance carrier subsequently makes a
payment to the office for those charges, the office will issue a credit to my credit
or debit card.

I hearby authorize Michelle B Deutch, D.D.S. and its designated employees to charge my credit/debit card as designated above.

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