Common Contracts
1 similar Financial Agreement contracts
Financial AgreementFinancial Agreement • February 4th, 2021
Payment for services rendered by Shallowford Family Dental Group is the sole responsibility of the patient or legal guardian. Payment is due upon receipt of services. All charges not covered by Insurance are the responsibility of the patient/guardian. We no longer accept assignment of secondary dental insurance towards payment. We will fill out the forms to allow reimbursement to the patient. If there is any default in payment for services, the patient or guardian agrees to be responsible for any costs necessary to collect this debt. (Court Costs, Collection Fees, Attorney
