Financial Policy Acknowledgement Please review our financial policy, then fill out the form to indicate you agree with the terms stated in the policy.We are committed to providing you with the best possible care. Our fees reflect our professional commitment to excellence. As the responsible party, this agreement is to inform you of your financial obligation to our practice. This financial agreement is intended to facilitate excellent service to you and your family while minimizing our administrative costs. All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a party to that contract. For the convenience of our patients we offer the following methods of payment of fees. Payment in full by cash, bank card, or alternate financing of each appointment as service is rendered. Alternate financing (payment plans) must be arranged before treatment is rendered. For insurance patients, we will accept payment directly from the insurance company only for that percentage the company will cover and do require that the deductible and non-covered fees be paid at each visit. Your co-payment may be adjusted after the time of service depending upon the final reconciliation of insurance payments. Bank charge cards – Visa, Mastercard, Discover and debit cards are accepted. We will gladly discuss your proposed treatment and answer any questions you might have as to the involvement of your benefit program in receiving this care. There is no interest or finance charge on current accounts. After 90days, all accounts are subject to a finance charge of 1.5% a month, which is an annual percentage rate of 18%. Name First Last Acknowledgement of receipt of financial policy*I have reviewed the financial policy.I have not reviewed the financial policy.NameBy typing your full name here, you are electronically signing this document. Today's date Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.