Common use of Payment Agreement Clause in Contracts

Payment Agreement. I understand and agree that payment is due at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and myself. I understand that this office will prepare any necessary dental reports and dental forms to assist me in making collection from my insurance company, and that any amount authorized to be paid directly to this office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment, regardless of insurance. If the patient is a minor, I am the parent and/or guardian of said patient and agree that I am responsible for all services rendered to the patient herein. I understand that if I suspend or terminate any care and treatment to me or any person referred to in the previous sentence any fees for professional services rendered will be immediately due and payable. Signature: (If Patient is a minor, Parent or Guardian must sign here and complete section below) Date: RESPONSIBLE PARTY Sex: M or F SIN DOB Street _( City ) Province ( ) Postal Code (Dr/Mr/Mrs/Miss) First Middle Last Jr/Sr Home Phone Work Phone Employer METHOD OF PAYMENT How will you pay for today’s visit? Cash Bank Check MasterCard Visa Card Other Charge Card Authorization By signing hereunder, I authorize Lakeside Dental to bill my charge card account should any balance for services rendered that remain outstanding for more than (60) sixty days. If the account information given expires or is otherwise discontinued, I agree to give Lakeside Dental information as to an alternate charge account, which may be used. My account is as follows: Visa MasterCard Interac Card # Exp Date Signature Date PATIENT CONSENT FORM FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION Privacy of your personal information is an important part of our office, just as providing you with quality dental care. We understand the importance of protecting your personal information and we are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and as transparent as possible about the way we handle your personal information. It is VERY important to us to provide this service to all of our patients. In this dental office, the dental centre manager acts as the privacy information officer. All team members who have come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Here is an outlined policy that our office follows to ensure you that: ● Only necessary information is collected about you ● We only share your information with your consent ● Storage, retention and proper destruction of your personal information complies with the existing legislation and privacy protection protocols ● Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law. Please do not hesitate to discuss our policies with me or any member of our office staff and be assured that every team member in our office is committed to ensuring that you receive the best quality dental care.

Payment Agreement. I understand A credit card number is required prior to the evaluation. Your card will not be charged for payment unless specifically authorized by you. However, we reserve the right to charge your credit/debit card for unpaid balances, violations of this payment agreement, returned checks and agree that payment is due any associated bank fees. A deposit of no less than 50% will be paid at the time services are rendered of the initial appointment by cash, check or credit/debit card (Visa, MasterCard). The remaining balance of will be paid at the feedback session, and prior to receiving a copy of the testing report. Additional fees may be added at a rate of $175 per hour if testing takes much longer than expected, or if we both agree that healthadditional testing would be beneficial. Typically this is not necessary, dental however, in either case you will be notified about this in advance before your account is charged. Additional fees may apply if an expedited report for this evaluation is required outside of a reasonably expected time frame (2-3 weeks after all testing is completed). In the event that your account becomes past due (60 days or more) and accident insurance policies are an arrangement between my insurance carrier and myselfwe have not made other arrangements for payment, then we reserve the right to charge the account indicated on page 2 of this agreement for the unpaid balance or use a collection agency until your account is reconciled. Authorization I authorize Xxxxxxxx XxXxxx, PsyD, to charge the credit/ debit card below for the following: q Do not charge card at this time, however, I understand that this office will prepare any necessary dental reports my account may be charged for the reasons stated above (Card information and dental forms signature still required) q This visit only $ q Balance due on account not to assist me in making collection from my insurance company, and that any amount authorized exceed $ q Recurring charges of $ to be paid directly charged every (frequency) From to this office will be credited to my account on receipt(date) (date) Check One: q Visa® q MasterCard® Name of person being evaluated: Cardholder Name: Cardholder Address: City: State: Zip: Credit Card Number: CVV: Exp. HoweverDate: Cardholder Signature: Date: If paying by check, please make checks payable to: Xxxxxxxx XxXxxx, PsyD I clearly understand have carefully read all the terms of the above guidelines and agree that all services rendered to me are charged directly abide by its guidelines. I have had an opportunity to me and ask questions acknowledge that I am personally responsible for payment, regardless entitled to receive a copy of insurancethis agreement. If the patient is a minor, I am the parent and/or guardian Signature of said patient and agree that I am responsible for all services rendered to the patient herein. I understand that if I suspend or terminate any care and treatment to me or any person referred to in the previous sentence any fees for professional services rendered will be immediately due and payable. Signature: (If Patient is a minor, Parent or Guardian must sign here and complete section below) Responsible Party Date: RESPONSIBLE PARTY Sex: M or F SIN DOB Street _( City ) Province ( ) Postal Code (Dr/Mr/Mrs/Miss) First Middle Last Jr/Sr Home Phone Work Phone Employer METHOD OF PAYMENT How will you pay for today’s visit? Cash Bank Check MasterCard Visa Card Other Charge Card Authorization By signing hereunder, I authorize Lakeside Dental to bill my charge card account should any balance for services rendered that remain outstanding for more than (60) sixty days. If the account information given expires or is otherwise discontinued, I agree to give Lakeside Dental information as to an alternate charge account, which may be used. My account is as follows: Visa MasterCard Interac Card # Exp Date Signature Date PATIENT CONSENT FORM FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION Privacy of your personal information is an important part of our office, just as providing you with quality dental care. We understand the importance of protecting your personal information and we are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and as transparent as possible about the way we handle your personal information. It is VERY important to us to provide this service to all of our patients. In this dental office, the dental centre manager acts as the privacy information officer. All team members who have come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Here is an outlined policy that our office follows to ensure you that: ● Only necessary information is collected about you ● We only share your information with your consent ● Storage, retention and proper destruction of your personal information complies with the existing legislation and privacy protection protocols ● Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law. Please do not hesitate to discuss our policies with me or any member of our office staff and be assured that every team member in our office is committed to ensuring that you receive the best quality dental care.

Payment Agreement. I understand and agree that payment is due at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and myselfAll child care payments will be collected using a Credit Card draft of Electronic fund Transfer using your banking account. I understand that this office service is will prepare any necessary dental reports and dental forms to assist me only continue while my child is in making collection from my insurance company, and that any amount authorized to be paid directly to this office will be credited to my account on receipta Child Development program. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment, regardless of insurance. If the patient is a minor, I am the parent and/or guardian of said patient and agree that I am responsible for all services rendered Please initial next to the patient hereinfollowing statements below. I understand that if I suspend wish to discontinue care; I must fill out a Child Development Cancellation/change form. If I don't I understand that I may not be refunded schedule charges I understand it is my responsibility to notify the Child Development Business Manager Xxxxxxxx Xxxxx 000-000-0000 xxx 000 of any changes of address,bank account information or terminate credit card information/ expiration date. The per-program registration fee is a one –time yearly fee. It is Non-refundable A $20.00 fee is applied to every returned transaction. The Ymca of Pueblo reserves the right to collect those fees before continuing any services or allowing further registrations for any programs. Electronic Funds Transfer (EFT) or Credit Card Authorization I authorize my bank to pre-authorized EFT or Credit Card charges, against my account for (child care service) payments indicated below. When the bank honors the EFT or Credit card by charging my account, such transfer shall constitute notice of payment due and treatment my receipt for the payment. Should any pre-authorized EFT or Credit Card not be honored by said bank when received by them, then it is understood that the payment is to be made by me or any person referred to in the previous sentence amount of said payment, plus a service charge (including all service charges from my institution, the YMCA of Pueblo and any fees third party collections institute.) It is further understood that if such payment is not honored by the bank or Credit Card Institution, then the YMCA at its discretion, may submit the amount due for professional services rendered will payment on a future date. • I choose to utilize the EFT option for monthly payment direct from my: Checking/Savings Account Bank Name Routing/Transit Number Acct. Number Name shown on account Authorized Signature Date • I choose to utilize the Credit Card Payment option for monthly payment- automatic direct charge Credit Card Type Visa MasterCard Card Holder Name Account Number Expiration Date Authorized Signature Date I choose one date: 1st of the Month I acknowledge the Payment Agreement. Signature Date Personal History Information Child’s Name Xxxxxxxx Mom_ Dad Guardian Family Dynamic Any custody Arrangements Please include paperwork Siblings of child: Name Birthdate Grade Name Birthdate Grade Name Birthdate Grade Name Birthdate Grade Has your child attended any Y Programs? Yes / No What activities does your child enjoy? What are your child’s main interests and hobbies? Does your child have any allergies or health issues that we should be immediately due aware of? Has your child had any specific unfavorable experiences in this type of program? What word best describes your child’s interaction with peers? What do you wish your child to gain by attending the B&A Program? Does your child wear an orthopedic appliance, glasses, or contacts? Please list any activities that you do not want your child to participate in: Waivers- Please read and payablesign carefully LIABILITY WAIVER The attached health History is correct so far as I know and the person herein described has permission to engage in all activities including field trips and photos for promotional purposes. Signature: (If Patient is a minor, Parent or Guardian must sign here and complete section below) Date: RESPONSIBLE PARTY Sex: M or F SIN DOB Street _( City ) Province ( ) Postal Code (Dr/Mr/Mrs/Miss) First Middle Last Jr/Sr Home Phone Work Phone Employer METHOD OF PAYMENT How will you pay for today’s visit? Cash Bank Check MasterCard Visa Card Other Charge Card Authorization By signing hereunder, I authorize Lakeside Dental to bill my charge card account should any balance for services rendered that remain outstanding for more than (60) sixty days. If the account information given expires or is otherwise discontinued, I agree to follow the rules, guidelines, procedures, and policies described in the Parent Information Packet. The Undersigned hereby agree to hold harmless and indemnify the YMCA of Pueblo and/ or any of its employees and/ or volunteers from and against any claims, demands, liability, costs of suit, damages, loss and/ or judgments in connection with any use of the YMCA properties. TRANSPORTATION AUTHORIZATION I hereby give Lakeside Dental information as permission to the YMCA of Pueblo to transport my child on the YMCA- provided Transportation. SUNSCREEN PERMISSION I hereby give permission for sunscreen to be applied to my child by Him/herself. In the event that my child forgot sunscreen, my child has permission to apply sunscreen that is provided by the YMCA. EMERGENCY AUTHORIZATION I hereby give permission to the allow medical personnel selected by the YMCA staff to order x-rays, routine tests and treatment for my child. In the event that I can not be reached in an alternate charge accountemergency, I hereby give permission to transport, to hospitalize, secure proper treatment for and to order injection and/ or anesthesia and/ or surgery for my child. I accept financial responsibility if such treatment is necessary. I understand that this consent does not waive or diminish my rights. Swimming Waiver I hereby give permission for my child to participate in swimming at the YMCA. Climbing Waiver I hereby acknowledge the inherent extreme risks in rock climbing, including climbing on artificial surfaces. I realize that those risks include, but are not limited to: falls from or contact with the walls or equipment, bad decision making, inattention of belayers or actions of other climbers, misuse or failure of equipment, holds which may have become loose or damaged, and accidents which cannot be usedforeseen. My account I acknowledge that the above list is as follows: Visa MasterCard Interac Card not inclusive of all possible risks associated with the use of the facilities and/or the sport of clinging and I agree that said list is in no way limits the extent or reach of this release. I VOLUNTARILY ASSUME ALL RISKS WITH FULL KNOWLEDGE AND APPRECIATION OF THE DANGERS AND RISKS INVOLVED. Insurance Information Child’s Legal Name School Insurance Company Policy/ Group # Exp Date Name or Policy Holder Relationship to child Guardian Signature Date PATIENT CONSENT FORM FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION Privacy of your personal information is an important part of our office, just as providing you with quality dental care. We understand the importance of protecting your personal information and we are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and as transparent as possible about the way we handle your personal information. It is VERY important to us to provide this service to all of our patients. In this dental office, the dental centre manager acts as the privacy information officer. All team members who have come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Here is an outlined policy that our office follows to ensure you that: ● Only necessary information is collected about you ● We only share your information with your consent ● Storage, retention and proper destruction of your personal information complies with the existing legislation and privacy protection protocols ● Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law. Please do not hesitate to discuss our policies with me or any member of our office staff and be assured that every team member in our office is committed to ensuring that you receive the best quality dental care.Guardian’s Printed

Payment Agreement. I understand and agree that payment is due at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and myself. I understand that this office will prepare any necessary dental reports and dental forms to assist me in making collection from my insurance company, and that any amount authorized to be paid directly to this office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment, regardless of insurance. If the patient is a minor, I am the parent and/or guardian of said patient and agree that I am responsible for ALL charges for services that are not covered by Medicare, Medicaid, or other medical insurance programs or plans, public or private, under which I am entitled to benefits. I agree to provide PharmcareUSA all documents and other information necessary for PharmcareUSA to obtain direct payment from such third party payers. I agree to pay all deductible amounts and other charges not covered by the assignment of benefits. I agree to and understand that I can obtain specific information as it relates to medication charges by directly contacting my PharmcareUSA pharmacy and or requesting my specific medication charges via sending an inquiry to my pharmacy via the PharmcareUSA website at xxx.xxxxxxxxxxxx.xxx. I agree to pay a late fee of 1.5% on any balance not paid within 30 days. PharmcareUSA reserves the right at any time to discontinue services rendered to the patient hereinfor any account with a past due balance. I understand that if I suspend or terminate any care and treatment to me or any person referred to in the previous sentence any fees for professional services rendered will be immediately due and payable. Signature: (If Patient is upon from a minor, Parent or Guardian must sign here and complete section below) Date: RESPONSIBLE PARTY Sex: M or F SIN DOB Street _( City ) Province ( ) Postal Code (Dr/Mr/Mrs/Miss) First Middle Last Jr/Sr Home Phone Work Phone Employer METHOD OF PAYMENT How will you pay for today’s visit? Cash Bank Check MasterCard Visa Card Other Charge Card Authorization By signing hereunderdischarge from a nursing facility, I authorize Lakeside Dental may be responsible for payment of medications released to bill my charge card account should client/resident. I also agree to pay PharmcareUSA for all collection fees, attorney's fees, court costs, and other expenses involved in collecting any balance for charges hereunder. The customer acknowledges that he has not rece ived any representations of promises concerning the pharmacy services rendered or the terms of this agreement other that remain outstanding for more than (60) sixty daysas set forth herein. If the account information given expires or is otherwise discontinued, As a resident of a nursing facility I agree to give Lakeside Dental information allow the nurse/facility representative to sign/acknowledge receipt of all equipment or services including prescription medications as well as receipt of all Patient Education materials. This agreement shall be governed by and construed in accordance with the laws (other than the conflict law rules) of the state the servicing PharmcareUSA is located. PharmcareUSA may assign this agreement to an alternate charge account, which may be usedany successor to PharmcareUSA's business. My account is as followsResident Printed Name: Visa MasterCard Interac Card # Exp Date Resident Signature Date PATIENT CONSENT FORM FOR COLLECTION/ / Patient’s Agent or Representative DATE / / Relationship to Patient (if resident unable to sign, USE AND DISCLOSURE OF PERSONAL INFORMATION Privacy Legal guardian, Representative Xxxxx, Relative, Representative of your personal information is an important part of our office, just as institution providing you with quality dental care. We understand the importance of protecting your personal information and we are committed care or Assisting Governmental Agency)  Please mail statement to collecting, using and disclosing your personal information responsibly. We also try to be as open and as transparent as possible about the way we handle your personal information. It is VERY important to us to provide this service to all of our patients. In this dental office, the dental centre manager acts as the privacy information officer. All team members who have come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information. Here is an outlined policy that our office follows to ensure you that: ● Only necessary information is collected about you ● We only share your information with your consent ● Storage, retention and proper destruction of your personal information complies with the existing legislation and privacy protection protocols ● Our privacy protocols comply with privacy legislation, standards of our regulatory body, the Royal College of Dental Surgeons of Ontario, and the law. Please do not hesitate to discuss our policies with me or any member of our office staff and be assured that every team member in our office is committed to ensuring that you receive the best quality dental care.Responsible Party – (Name) (Address)_ (Town) (State) (Zip Code)_