OVERDUE BALANCE. An account with an unpaid balance past 90 days will be sent to the collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt: an interest rate of 21% on the unpaid balance from the last date of service, attorney fees, court fees and any other fees associated with the collection of your debt.
OVERDUE BALANCE. An account with an unpaid balance past 90 days will be sent to the collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt: an interest rate of 21% on the unpaid balance from the last date of service, attorney fees, court fees and any other fees associated with the collection of your debt. FEE FOR MISSED APPOINTMENT IF 24-HOUR NOTICE NOT GIVEN To reschedule or cancel an appointment, you must notify us at lease twenty-four (24) hours in advance to avoid a missed appointment fee of $50. We reserve the right to terminate professional treatment of any patient when scheduled appointments are not kept. CONSENT & AUTHORIZATION I hereby do authorize dental treatment and agree to pay all related professional fees. Fees not covered by my dental insurance will be promptly paid upon notification from this office. I have read and understand this document in its entirety. Without any reservations, I agree to abide by the policies outlined herein. FORM COMPLETED BY
OVERDUE BALANCE. An account with an unpaid balance past 90 days will be sent to the collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt: an interest rate of 21% on the unpaid balance from the last date of service, attorney fees, court fees and any other fees associated with the collection of your debt. BROKEN OR MISSED APPOINTMENTS Appointments not kept or changed with less than 24 hours notice are considered broken. Broken appointments will be rescheduled during the morning hours and subject to additional fees. Broken appointments prevent others from receiving the dental care they deserve. We take them seriously so please be considerate and inform us in advance if you need to change your appointment. FEE FOR MISSED APPOINTMENT IF 24-HOUR NOTICE NOT GIVEN To reschedule or cancel an appointment, you must notify us at lease twenty-four (24) hours in advance to avoid a missed appointment fee of $25. We reserve the right to terminate professional treatment of any patient when scheduled appointments are not kept. RECORDS AND REIMBURSEMENTS Original records including radiographs are the property of this office. If you desire, we will provide you with a copy of your record or radiographs for a nominal duplication fee. CONSENT & AUTHORIZATION I hereby do authorize dental treatment and agree to pay all related professional fees. Fees not covered by my dental insurance will be promptly paid upon notification from this office. I have read and understand this document in its entirety, outlining office policies and financial policies of Xxxx Xxxxxxxxxx, DDS, PL. Without any reservations, I agree to abide by the policies outlined herein. FORM COMPLETED BY Name Signature IN CASE OF A CHILD: Relationship to child Date Are you the person legally responsible for this child? Yes No Reviewed by staff member Date Acknowledgement of Receipt of Notice of Privacy Practices Xx. Xxxx Xxxxxxxxxx * You May Refuse to Sign This Acknowledgment* I have received a copy of this office’s Notice of Privacy Practices. Print Name: Signature: Date: For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement
OVERDUE BALANCE. An account with an unpaid balance past 90 days will be sent to the collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt: an interest rate of 21% on the unpaid balance from the last date of service, attorney fees, collection agency fees, court fees and any other fees associated with the collection of your debt. BROKEN OR MISSED APPOINTMENTS Appointments not kept or changed with less than 48 hours notice are considered broken. Broken appointments will be rescheduled during the morning hours and subject to additional fees. Broken appointments prevent others from receiving the dental care they deserve. We take them seriously so please be considerate and inform us in advance if you need to change your appointment. FEE FOR MISSED APPOINTMENT IF 48-HOUR NOTICE NOT GIVEN To reschedule or cancel an appointment, you must notify us at lease twenty-four (24) hours in advance to avoid a missed appointment fee of $50. We reserve the right to terminate professional treatment of any patient when scheduled appointments are not kept. RECORDS AND REIMBURSEMENTS Original records including radiographs are the property of this office. If you desire we will provide you with a copy of your record or radiographs for a nominal duplication fee. CONSENT & AUTHORIZATION
OVERDUE BALANCE. An account with an unpaid balance past 90 days will be sent to the collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt: an interest rate of 21% on the unpaid balance from the last date of service, attorney fees, court fees and any other fees associated with the collection of your debt. BROKEN OR MISSED APPOINTMENTS Appointments not kept or changed with less than 24 hours notice are considered broken. Broken appointments will be rescheduled during the morning hours and subject to additional fees. Broken appointments prevent others from receiving the dental care they deserve. We take them seriously so please be considerate and inform us in advance if you need to change your appointment. FEE FOR MISSED APPOINTMENT IF 24-HOUR NOTICE NOT GIVEN To reschedule or cancel an appointment, you must notify us at least twenty-four (24) hours in advance to avoid a missed appointment fee of $50. We reserve the right to terminate professional treatment of any patient when scheduled appointments are not kept. RECORDS AND REIMBURSEMENTS Original records including radiographs are the property of this office. If you desire we will provide you with a copy of your record or radiographs for a nominal duplication fee of $25.00. CONSENT & AUTHORIZATION I hereby do authorize dental treatment and agree to pay all related professional fees. Fees not covered by my dental insurance will be promptly paid upon notification from this office. I have read and understand this document in its entirety, outlining office policies and financial policies of Xxxxxxx Xxxxxxxx DDS. Without any reservations, I agree to abide by the policies outlined herein. Name_____________________________________Signature___________________________________
OVERDUE BALANCE. If payment is not received within 30 days of the mailing date of the statement, we will attempt to send another statement. After 60 days from the date of the first notice, your account will be turned over to a collections agency and you will have to make payments directly to them. We will no longer be able to accept payments on balances sent to a collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt, which may include attorney fees, court fees, and any other fees associated with the collection of your debt. Moreover, at this time we may send you a notice that we will no longer be accepting you as our patient due to the delinquency in payment. Interest charges will be applied to all balances not paid within 30 days of the billing date at a rate of 10% per year. LATE OR MISSED APPOINTMENTS Our appointments are carefully scheduled around the providers’ limited time and availability. Therefore, arriving more than 15 minutes late or missing your appointment will interfere with the pre-set schedule and potentially impact other patients. In fairness to the other scheduled patients who show up on time for their appointments, we may not always be able to fit in a late arrival into the schedule. We may have to re-schedule the appointment unless there is an opening in the schedule that we had not expected. We notify patients of their appointment 2 weeks prior, as well as 2 days prior, by email, and 1-day prior by their preferred method, such as text, e-mail, or phone call. Keeping track of appointments is your responsibility regardless of whether a reminder is received or not. It is your responsibility to keep your contact information current with our office.
