Financial Agreement_New

Financial Agreement
Last Name
First Name
Birthdate
Date 6/12/2024
[dateLastBW]For my convenience, this office may release my information to my insurance company, and receive payment directly from them. I also hereby authorize payment directly to Dr. Pierson. I understand that I am responsible for any and all fees not paid by the insurance carrier.

* We’re happy to help you maximize your benefits, but please understand it is our experience that some dental benefit providers are making changes that may or may not be communicated to you. We promise to be fair and consistent with all our patients, but we have no control over what insurance companies ultimately do or don’t cover and at what rate.”We will estimate your co-payment (if any) as close as possible depending on your insurance. Once the claim has been processed by your insurance, you will be billed if there is any difference between our estimate and what the insurance processed.

* PAYMENT IS DUE ON THE DAY OF SERVICE, payments can be made in advance or through outside financing with credit approval.
* No treatment will be allowed if balance is over 30 days past due. If sent to collections, I agree to pay all related fees and court costs.
* A fee of $50 will be charged to patients who miss or cancel more than 1 time in a calender year without 48 hours notice.

If any payment or portion thereof due under this Agreement is not recieved by our office within ten (10) days after the due date thereof or if insurance is involved, ten (10) days after billing and receipt of funds from insurance company, patient agrees to pay Doctor (Pierson Dental), in addition to the payment due, a late service charge of 1.25 percent (1.25%) fee per month and a15.000% annual fee of the amount of such payment due and unpaid.

In case collection efforts or suit or action on behalf of the Doctor (Pierson Dental) is instituted to collect any sums due to the doctor (pierson Dental), under this Agreement, patient agrees to pay all of Doctor`s (Pierson Dental) costs of collection incurred, together with reasonable attorney`s fees up to 25 percent, in connection therewith which amount is an additional sum over and above the amount of patient`s indebtedness to Doctor (Pierson Dental).