Financial AgreementPayment in full for all charges is required at time of visit, unless prior arrangements have been made.Date: 4/20/2021
Signature will be recorded later.
You, the patient, are ultimately responsible for payment in full on your account, not the insurance company. We do, however, file dental insurance claims as a courtesy to our patients. We can only make estimates regarding your insurance benefits based on the information provided by you and the insurance company. ln the event your insurance company does not pay as much as expected, the remaining balance is due and payable immediately by you, the patient.Collection Proceedingsl/We hereby assign directly to North Valley Dentistry insurance benefits otherwise payable to me/us. l/We hereby authorize the release of any information relating to any claims. l/We understand l/we are financially responsible for charges not paid by this assignment.Missed Appointmentsln the event your account is turned over to a collection agency for non-payment or other delinquency, you will be responsible for payment of any and all reasonable collection costs (currently 36% of collection balance) and/or attorney fees, in addition to the balance owed. Any account turned over to a collection agency forfeits any past special fees and/or discounts. Such special fees and/or discounts will be reversed and you will be responsible for payment of regular fee for procedures at the time of service.Delinquent AccountsInsurance FilingMissed appointments (less than 24 business hours` notice) are a significant contributor to rising health care costs. Individuals who fail to show for an appointment will be assessed a $50 fee per half hour of missed appointment time.
Monday 9 am-5 pm
Tuesday 9 am-5 pm
Wednesday 9 am-5 pm
Thursday 8 am-2 pmAssignment of Insurance BenefitsAll delinquent accounts (30 days or older) are subject to reasonable service charges and/or legal interest rates.Financial AgreementResponsible Party Signature:Responsible Party Signature (Enter Full Name):14001 N 7th St, D108
Phoenix, Arizona 85022