Financial Agreement First Name(Required)Last Name(Required)Birthdate(Required) DD slash MM slash YYYY For my convenience, this office may release my information to my insurance company, and receive payment directly from them. I understand that if I begin major treatment that involves lab work, I will be responsible for the fee at that time. 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. Benefits do not rollover and some procedures will need pre-approval by insurance plans, those preauthorizations may take up to 6 weeks. I understand that I will be responsible to pay the fee, for any treatment completed, on the same day of the appointment. I will pay a fee for appointments broken without 24 hours notice. Treatment plans may change, and I will be responsible for the work actually done. If insurance benefits apply, ESTIMATED patient’s co-payments and deductibles are due at the time of service. We ask that you give us at least 24 hours’ notice, if you are unable to make your scheduled appointment time. (This courtesy makes it possible to give your reserved time to another patient who would like it.) Our office will attempt to contact you up to 3 times to confirm your appointment. Appointments MUST be confirmed. If NO CONFIRMATION is made, your appointment may be cancelled. There will be a charge of $50.00 for missed appointments. If you are 10 Minutes late to your scheduled appointment, we may not be able to accommodate you. If we are not able to see you due to this tardy, it will be considered a missed appointment and could be subject to a missed appointment fee. Date(Required) DD slash MM slash YYYY Signature(Required)
