FINANCIAL POLICY AND DENTAL INSURANCE FORM

FORM #3 --- Please compete these forms, and bring them with you for your first appointment. It will save you several minutes! Thank You, Dr. Waldrop and staff. Please understand that payment of your bill is considered a part of your treatment plan. If you are unable to pay in full, please inform my front desk personnel in advance so that we may discuss the financing options available to you. All billing is payable upon receipt in full, except where assignment of insurance benefits have been accepted, or alternate payment methods have been arranged in advance. Regarding Insurance: We may accept assignment of insurance benefits on your behalf. This means that your insurance company will pay us instead of you. However, your insurance policy is a contract between you and your insurance company. We have no control over thier decisions or the amount they decide to pay. Often we can predetermine your benefits if emergency care is not required by sending a pre-treatment estimate to your insurance carrier. You may have a deductible or co-payment. All deductibles and co-payments are due at the time services unless prior arrangements have been made. You should be aware that your insurance company will not guarantee payment over the telephone. We will not know the exact amount they will pay until they respond to your pre-treatment estimate by mail. Regardless of what your insurance company decides to pay, you remain fully responsible for payment of your bill in a timely manner. Once payment is received on your claim, we will send you a bill for the remaining balance on your account if there is any. Please understand that by signing this instrument, that should your account be referred for collection, you will be held responsible for reasonable attorney and collection fees in addition to the account balance, and the Patient's delinquent account is subject to a 1.5% interest per month or 18% APR. I have read and understand the above financial policies. By signing below, I acknowledge responsibility and agree to the terms as written above. ________________________________________ Signature of Responsible party ________________________________________ Date ________________________________________ Witness © 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.