Financial Policy Form

Please correct the errors described below.

The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

ALL emergency dental services, or any dental service performed without previous financial arrangements, must be paid for in full at the time services are rendered.


As a courtesy to our patients, this office will prepare and file the patient’s insurance forms, assist in making collections from DENTAL insurance companies (WE WILL NOT FILE TO MEDICAL INSURANCE), and credit any such collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient, and he or she is personally responsible for payment of all dental services not paid by the insurance company.

As the patient, I understand that due to insurance policy changes and/or necessary changes in treatment plans, the insurance coverage may vary from the estimated treatment calculation. I acknowledge that this is an estimate only, and I understand that I, not the insurance company, am ultimately responsible for payment in full for all services rendered.

I understand that all services are due to be paid in full within sixty (60) days of the date of service, whether or not my insurance benefits have been received. Should my account exceed sixty days, one and one-half percent (1.5%) interest per month (18% per year) will be charged. There are no guarantees of insurance benefits.

I grant my permission to your or your assignee, to telephone me at my home, work, or personal number to discuss matters related to this form.

I have read the above conditions of treatment and payment, and I agree to their content.

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.

I certify that a member of the office staff offered to explain questions I have regarding this form.

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