Common Contracts
1 similar Patient Payment Agreement contracts
PATIENT PAYMENT AGREEMENTPatient Payment Agreement • April 28th, 2016
This is to certify the above treatment fees and checked payment option has been explained to me and I fully understand the nature of the treatment recommended. I understand and agree that if my insurance does not pay my insurance claim within 45 days, I am responsible for any balance due. I agree to pay reasonable attorney’s fees, court costs and collection costs incurred by Island View Dental in collection and enforcement of the debt. The above fees will be honored for 6 months or until commencement of treatment, whichever occurs first.
