Common Contracts
1 similar Financial Agreement contracts
FINANCIAL AGREEMENTFinancial Agreement • March 21st, 2019
Please remember that some insurance companies pay fixed allowances for procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance. To control billing costs, we request that payment be made at the time of services. The patient and or responsible party agree to pay INTEREST at the rate of 1 ½ % per month and all costs of collections including reasonable attorneys fees, on all amounts due on accounts more than 60 days from the date of service. To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of the patient’s medical record. I further hereby assign all dental benefits, to which I am entitled, including private insurance and other health plans to: Dental Doctors of Somerset, 84 Glastonbury Blvd, Suite 203, Glastonbury, CT 06033.
