Financial Agreement and/or Insurance Signature Form
I understand and agree as a patient and/or guarantor whether insured or self-pay that in consideration of the services to be rendered, that I hereby individually obligate myself to pay the account of the dental office in accordance with the regular rates, terms and interest (18% interest per annum on accounts thirty days past due) on the unpaid balance set out by the office. ln the event that it is necessary to place the account with a collection agency to collect the balance due, and additional 35%of the principle balance due will be added. in addition, should legal action become necessary to collect the balance due, l understand that I will be responsible for but not limited to reasonable attorneys fees, interest and court costs. I also understand that if my account is placed with an agency for collection or placed with an attorney for legal action that a credit report may be pulled for the sole purpose of coliecting the delinquent account. I hereby authorize payment of the dental benefits, otherwise payable to me, directly to the above named dental entity. I understand that I will be charged $30.00 for each returned check.
