Financial Agreement

  • For my convenience, this office may release my information to my insurance company and receive payment directly from them.
  • If sent to collections, I agree to pay all related fees and court costs.
  • Every effort will be made to help me with my insurance, but if they do not pay as expected, I will still be responsible.
  • IA Medicaid insurance offers a maximum of $1000.00 starting July 1st - June 30th.
  • I understand that I will be responsible for paying the fee for any treatment completed on the same day of the appointment.
  • Treatment plans may change, and I will be responsible for the work done.
  • If insurance benefits apply, ESTIMATED non-covered portions of services and/or any deductibles are due at the time of service.
  • If there is an outstanding balance on my account, I understand the office has the right to dismiss me from the office.
  • Because instruments, chairs, and personnel are reserved exclusively for your appointment, there will be a $50.00 fee charged for changed or broken appointments less than 24 hours in advance.
  • After one missed appointment, the result could be a release of dental care from Rapids Dental.

agree to these financial terms and conditions.

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