As a patient of the office of ORWICK DENTAL CARE, I understand that as a recipient of dental treatment, I, the undersigned, am responsible for all charges regardless of my circumstances for reimbursement. Full payment is due at the time of delivery of service. I understand that a fee is charged for all office visits, dental examinations, and dental reports. I agree that the determination of the professional services to be rendered by my dentist and the fees to compensate the dental office for these services are matters which concern my dentist and me. I understand that I have the primary duty and obligation to pay my dentist for services rendered, notwithstanding any contract that I may have with any third party payer (i.e., insurance company, employer, etc…)
The undersigned hereby authorizes the release of any and all information or documents to all parties related to obtaining my insurance benefits for claims submitted on behalf of myself and/or dependants. I further expressly agree and acknowledge that my signature on this document authorizes this dental office and all necessary parties to submit claims to obtain benefits, for services rendered, without obtaining my signature on each and every claim to be submitted for myself and/or dependants, and that I will be bound by this signature as if the undersigned had personally signed the particular claim.
I hereby authorize my insurance company to pay and hereby assign directly to ORWICK DENTAL CARE all benefits. I understand that I am financially responsible for all charges incurred. I further acknowledge that any insurance benefits, when received by and paid will be credited to my account, in accordance with my insurance company's assignment. Any unpaid charges are my responsibility. Full payment is due at the time of service except if otherwise arranged or mandated by law.
Should I fail to pay any unpaid charges for more than thirty (30) days, I authorize a monthly service fee to be added to my unpaid balance in the amount of $25 for each month the balance remains unpaid. Accounts with no activity for more than sixty (60) days may be forwarded to a collection representative for action. If I default and my account is referred to a collection agency or attorney, I will be responsible for all costs associated with the collection of monies owed, including but not limited to, interest, court costs, collection, collection agency and attorney fees. Any and all advance collection fees incurred by Orwick Dental Care will be included in my final bill. I understand and agree that some additional charges may come through from my treatments that are not included in the initial estimated bill.
I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO KNOW WHAT THE TERMS OF MY INSURANCE
ARE, AND IN COMPLIANCE WITH THOSE TERSM, AGREE TO THE FOLLOWING:
1. Providing the Orwick Dental Office with
complete and accurate billing information, including, but not limited to, a
current insurance card and authorization numbers. I further understand that
I am responsible for all visits and procedures not properly authorized.
2. I will pay all applicable co-pays and outstanding patient balances as they
become due. All co-pays and patient balances are due at each visit.
I give my consent to Orwick Dental Care to provide dental care and treatment
to the below named patient deemed necessary and proper in diagnosing or treating
his/her/my dental condition.
I HAVE READ AND AGREE TO ALL THE TERMS OUTLINED ABOVE
SIGNED (patient or guarantor): ____________________________________ Date: __________
FOR (print patient name): ________________________________________________________