Thank you for choosing Durham Dental Studio for your dental care. In order to avoid any misunderstandings regarding financial arrangements, we ask that all patients review and sign the following financial agreement. By signing this form, you agree to the terms outlined below.
1. Financial Responsibility
- Payment for Services: Payment is due at the time services are rendered unless other arrangements have been made in advance. If you are unable to pay the full amount at the time of service, please discuss payment options with our office before your appointment.
- Accepted Forms of Payment: We accept cash, check, credit card, or other methods, such as CareCredit. Payments can be made in full, or financing options may be available.
2. Insurance
- Insurance Information: If you have dental insurance, please provide the necessary information before your first appointment. We will file insurance claims on your behalf, but it is ultimately your responsibility to understand your insurance policy and any out-of-pocket costs, including deductibles, co-pays, and non-covered services.
- Co-pays and Deductibles: Any co-pays or deductibles are due at the time of service. If your insurance coverage changes or a claim is denied, you will be responsible for the balance.
- Non-Covered Services: If your treatment is not covered by insurance, you will be responsible for the full cost of those services. We can discuss payment arrangements if necessary.
3. Missed Appointments
- A $50 missed appointment fee will be charged if you fail to show up for an appointment without providing at least 24 hours' notice. This fee is not covered by insurance and is the responsibility of the patient.
By signing below, I acknowledge that I have read, understand, and agree to the terms of this Financial Agreement. I understand that I am responsible for the payment of all services rendered at Durham Dental Studio, including any co-pays, deductibles, and fees for services not covered by my insurance.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
