- I understand that I am responsible for all fees related to my dental care and treatment.
- I understand that full payment for all dental treatment is to be paid at the time of service. For your convenience we accept Cash, CareCredit, Discover, MasterCard and Visa.
- I understand that any and all account balances over 30 days old may incur a monthly interest charge at the maximum rate.
- I understand that if any electronic authorization or debit sent or provided to Divine Dental Center for payment is not honored upon first presentation, regardless of the reason, even if the electronic authorization was later honored. I will be charged the maximum allowable service charge of $30.
- I understand that if my account is not timely paid, my account may be turned over to collection agency. In addition to paying my balance, I agree to pay all Attorneys fees, collection and/or other court costs.
- Divine Dental Center reserves the right to charge a $35 fee for any appointment not kept by the patient. After two (2) broken or missed appointments, the dentist retains the right to discontinue elective treatment.
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- I understand that my insurance policy is a contract between my insurance company and myself. Divine Dental Center and its employees are not parties to my contract with my insurance company.
- I understand that I am ultimately responsible for any and all balances, even if my insurance company agrees to pay a balance and later does not pay.
- I understand that I may be given the option of only paying my estimated portion (that portion not covered by insurance) at the time of services. As a courtesy, the office will send my claim to my insurance company. If my insurance fails to pay the balance, the balance is my responsibility and payment is due in full.
- I understand that if my first visit is an emergency visit, I will be responsible for payment of services in full at the time of the visit. As a courtesy, Divine Dental Center will provide to me the necessary documents to file to my insurance company for reimbursement.
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