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                                                               I also understand that the NOTICE OF PRIVACY
COLLECTIONS                                                    PRACTICE specs are presented in a binder in our waiting
                                                               room for you to review. If you would like a copy please
Over the past few years, there have been an extremely
                                                               ask at the front desk.
significant number of incidences where patients opt not to
pay their dental bills. If payment is not RECEIVED in
office within 30 days your unpaid balance will incur a
$2.00 a month “billing” charge. In the event that              I, ______________________________________________
payment is not RECEIVED in office within 90 days after         authorize_______________________________________
services have been fulfilled to you or the person(s) you are
jwill be suspended.                                            ________________________________________________

You or your family’s dental needs are our #1 priority.         ________________________________________________
Payments for work facilitated should be your #1 priority.      to discuss my treatment plan.
Please keep in mind, as our office grants you a 90 day
grace period after services are rendered; however after 90
days our office utilizes ZERO TOLERANCE contra                 3    Signature Of Patient / Parent or Guardian       Date
patient payment discrepancies.

Other collection protocol utilizes an array of collection      ARE YOU AN INSURANCE PATIENT?                      If
resources to report delinquency after 90 days, as well as      YES, I understand that my insurance company will NOT
collections attorneys, not a collection agency, to recover     pay 100% for my dental needs or for my dependents.
compensation for work facilitated. Thus it is mandatory        I understand that when using my insurance that I am
for our office to make a copy of your driver’s license         responsible to keep up with my Explanation of Benefits
prior to seeing the doctor.                                    (EOB), Eligibility, and Policy Limitations regarding my
I understand that I will be honest, righteous and forthright   own insurance coverage.
to make my payments. If I am not able to make payments I
will ask to set up a monthly payment plan as to avoid the      I UNDERSTAND MY INSURANCE COVERAGE IS
COLLECTION protocol. Initials                                  BROKEN INTO PROPORTIONAL SEGMENTS AS:
Of Patient / Parent or Guardian __________________ 1           PREVENTATIVE 100%/ BASIC 80%/ MAJOR 50% -
                                                               COVERAGE. *The percentage provided my not reflect
                                                               your actual coverage but is the average for nearly 90% of
NSF & STOP PAYMENT OF CHECKS                                   dental coverage
In the State of Florida writing a check that does not have     If payment is not made when you are billed our office may
the funds to post payment for the check is a CIVIL             suspend your account. Keep in mind that you may have an
violation of Florida State Law and we are obliged under        out of pocket expense with your services
sate law to report these violations. You will be charged
$30.00 for any check that is NSF and your case will be         If you do not have insurance listed below you must pay for
immediately forwarded to Flagler County DA’s office            services at the time they are facilitated. If our office does
(John Turner). The DA will then prosecute you on behalf        not hold a network contract with your company our office
of the state. All attorney and court costs will be your        will not be mailed an insurance check.

Stopping payment of a check is a CRIMINAL violation
                                                               I understand the provisions clarified to me regarding my
which may be processed as a 1st degree misdemeanor or a
                                                               financial responsibilities and personal / family insurance
felony. If you put stop payment on a check please notify us
                                                               management. I understand that if my insurance doesn’t pay
first to make alternate arrangements for payment. We ARE
                                                               for services, I’m responsible for the difference
required by state law to report checks that were STOPPED
FOR PAYMENT to Flagler County Sheriff’s office.                Of Patient / Parent or Guardian                            4
CHECK WITHOUT NOTIFYING US.                                    I understand and agree that (regardless of my insurance
                                                               status). I am ultimately responsible for the balance of my
2 I understand the severities of ill managed check writing     account for any dental services rendered. If my account
and the consequences of facilitating such an action            should become delinquent in arrears and sent to collections, I
Initials________________                                       AGREE to pay for all collection costs, Attorneys costs and
Of Patient / Parent or Guardian                            2   court costs in order to collect my debt EACH time I have a
                                                               visit within the office for not only myself but for any
By signing this you understand that our office upholds all     Signature Patient /Parent or
HIPPA laws that basically state that your private “patient”    Guardian______________________Date_________                  5
information will not be shared with any 3rd parties other
than a doctor, or Health Care Provider or Business                    PLEASE SIGN / INITIAL IN BOXES
Associates catering the welfare of your account                              1 THROUGH 5 OR
                                                                   THIS FORM HAS NOT BEEN COMPLETED!