Payment Policy for Healthcare Professional
PAYMENT POLICY
Payment for services is due at the time the services are rendered. For your convenience, we accept cash, checks, money orders, Visa, Mastercard and American Express.
Returned Checks will be charged a $15.00 handling fee. Balances over 30 days will be subject to interest charges of 1.5 percent per month (18% per annum). A minimum charge of $25.00 will be made for missed appointments and appointments cancelled without 24 hours advance notice.
If you have dental insurance, we will help you receive your maximum allowable benefits, however you remain responsible for payment if your claim is rejected.
If you have any questions concerning your account, please call our office for an explanation.
I hereby confirm that I have read the above payment policy and agree to and accept it.
Date: [DATE, ex. Wednesday, June 11, 1998]
______________________________________
Name:
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