Jeremy Wiggins, DDS
     
 

Financial Agreement: This is an agreement between Dentistry “4” Children, LLP as creditor, and the Responsible Party named on this form.

In this agreement the words “you,” “your,” and “yours” refers to the Responsible Party. The word “account” refers to the account that has been established in your name to which charges are made and payments credited. The words, “we,” “us” and “our” refers to Dentistry “4” Children, LLP.

By executing this agreement, you are agreeing to pay for all services that are received.

Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account and any payments or credits applied to your account during the month.

Payments: Unless other arrangements are approved by us in writing, the balance on your statement is due and payable when the statement is issued and is past due if not paid within 30 days of the closing date.

Charges to Account: We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the time of service.

Payment options if you do not have insurance:
A. You choose to pay by __cash, __check or __credit card on the day that treatment is rendered.
B. On treatment involving laboratory fees, (space maintainer, retainer, orthodontic appliance) you may chose to pay 50% on the preparation date and the balance upon completion (approx. three weeks).
C. On extensive treatment, you may prefer to secure a bank, credit union or other third-party financing for the entire amount and make payments to the lending institution.

Payment options if you have insurance:
A. You choose to pay your deductible, co-payments
and/or any out-of-pocket portions at the time services are rendered by __cash, __check or __credit card.
B. You choose to pay all of your treatment by __cash, __check or __credit card. We will bill your insurance and request your insurance carrier send their payment directly to you.
C. For visits under $100, payment is expected at the time of service regardless of insurance. We will bill your insurance carrier and request your insurance carrier send their payment directly to you.

Required payments: Any co-payments required by an insurance company must be paid at the time of service. This is an insurance requirement.

Returned checks: There is a fee ($20) for any checks returned by the bank.

Insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. We will bill your primary insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination. You agree to pay any portion of the charges not covered by insurance. We accept no responsibility in collecting overdue insurance claims or negotiating settlement on disputed claims. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it. Failure to obtain the referral and/or preauthorization may result in a lower payment from the insurance company or denial of the claim.

Your Insurance company is required by the Idaho Insurance Commissioner to process, pay or reject all insurance claims within a reasonable amount of time. On day 31, any balance on your account becomes your responsibility. Balances not paid within the following 60 days will be subject to interest charges and/or collections.

 

 Finance Charge: A finance charge will be imposed on each item of your account which has not been paid within 90 days of the date the item was added to the account. The Finance Charge will be computed at the rate of one and a half percent (1.5%) per month or an Annual Percentage Rate of eighteen (18%) percent. The finance charge on your account is computed by applying the periodic rate (1.5%) to the “overdue balance” of your account. The “overdue balance” of your account is calculated by taking the balance owed ninety (90) days ago, and then subtracting any payments or credits applied to the account during that time. The minimum Finance Charge is $1.99.

Orthodontic Payment Options: Orthodontic payment arrangements will be made before treatment begins and are contracted on an individual basis.

Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we must refer your account to a collection agency, you agree to pay all of the collection costs which are incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyer’s fees which we incur plus all court costs. In case of suit, you agree the venue shall be in Nez Perce County, Idaho.

Appointment Commitment: In order to best meet the needs of our patients and their families we trust that you will arrive on time for your scheduled appointment. When we schedule an appointment for your child we expect you to arrive on time. If you are late we will do our best to fit you into our schedule; however, it may be necessary to reschedule your child’s appointment. We do not allow repeated cancellations or short-notice changes as this puts our partnership with you in jeopardy. We may suggest that you seek care from another service provider. Patients who do not show up on time for an appointment, or cancel with less than 24 hours notice may be charged a $20 fee. This fee must be paid before a new appointment is scheduled.

Credit History: You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as a credit bureau.

Waiver of Confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent.

Transferring of Records: You will need to request in writing if you want to have copies of your records sent to another doctor or organization (we reserve the right to request a copying fee up to $25). You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information including your payment history.

Personal Injury: If the patient is being treated as part of a personal injury lawsuit or claim, we will bill insurance upon request. Payment of the bill remains the your responsibility.

Effective Date: Once you have signed this agreement, you agree to all of the terms and conditions contained herein and the agreement will be in full force and effect.