Common Contracts
1 similar Financial Policy contracts
Financial Policy This is an agreement between Dentistry by Design, located in Minnetonka Minnesota, and the Patient named on this form. By executing this agreement, you are agreeing to pay for all services that are received.Financial Policy • March 6th, 2018
Insurance: Insurance is a contract between you and your insurance company. We are NOT party to this contract. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility. You agree to pay any portion of the charges for services rendered but not covered by your plan or not paid (denied) by your insurance. You must inform us if you lose or are about to lose your insurance coverage. Any services rendered after insurance eligibility terminates will be charged at our standard fees. By signing below, you give Dentistry by Design the permission to release any information needed to your insurance agency or respective healthcare provider and assign the insurance benefits over to your dental clinic: Dentistry by Design, Atif H. Rizvi, DDS. The above-named doctor and facility may use your healthcare information and may disclose such information to
