Collections Policy. I understand that it is my responsibility to provide my correct/updated insurance information and that this office will bill my insurance as a courtesy to me. However, regardless of insurance coverage, I agree that it is and shall remain my responsibility to pay all amounts owing as set forth here-in. I agree that after 90 days interest will accrue on all past-due amounts at the rate of 18%per annum. (1.5% per month) until paid in full. In the event any amount(s) is/are referred to a third party debt collections agency, I agree in addition to any other amount(s) allowed by law, (such as interest, court costs, reasonable attorney’s fees, etc) I will also be responsible for a collection fee of up to 40% of the principal amount(s) owing as allowed by Utah Code Annotated, sec 12-1-11. The terms of this paragraph shall apply to all amount(s) incurred by me or by any individual for whom I have legal responsibility whether such amount(s) are incurred today or after today. 5. 48 hour cancellation policy: Appointments are reserved exclusively for you. As a health benefit to you, we may offer to move your appointment to an earlier time if openings arise. Smiles for Everyone reserves the right to charge a $50.00 fee per hour for any appointment that is missed/late or canceled without a 48-business hour advanced notice. If you are over 20 minutes late for your appointment we will automatically cancel your appointment time and the 48- business hour late cancellation policy will apply. I have read, understand and agree to all of the terms in the Agreement for Dental Services. Responsible Party’s name (PRINT) Signature Date PATIENT INFORMATION We are pleased to welcome you to our office. Please take a few minutes to fill out this form as completely as you can. If you have any questions we will be glad to help. Please present your insurance card to receptionist Personal Information Last Name First Name M.I. Date of Birth Social Security No. Male Female Married Not Married Cell Phone Number Home Phone Number Work Phone Number Home address City State Zip Code Email address Employer Occupation Employer Address City State Emergency Contact Phone Relation Your preferred contact method? Phone Text Email Postcard How did you hear about us? Who may we think for your referral? Please be aware that insurance information is an estimate only We do our best to obtain the most accurate insurance information available to us Many insurances implemented cost cutting changes which may have...
Collections Policy. Servicer shall be entitled to make exceptions to its general collections policy for individual Obligors, but only to the extent as is provided for in its Credit and Collection Policy.
Collections Policy a. The Credit Department is responsible for contacting customers with past due accounts
Collections Policy. In the event of nonpayment, Practice reserves the right to turn your account over to a collection agency or attorney in order to obtain payment of fees owed.
Collections Policy
