financial agreement form fillable .pdf

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Original filename: financial_agreement_form_fillable.pdf
Title: Microsoft Word - financial_agreement_form.docx
Author: Short Hills Design

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Kevin  A.  Harrison,  DDS,PS  
16410  Smokey  Pt.  Blvd.    #305  
Arlington,  WA    98223  
360-­‐653-­‐7654  
www.kevinaharrisondds.com  
Financial  Agreement  and  Authorization  for  Treatment  
         I  authorize  Kevin  A.  Harrison,  DDS,  PS  to  provide  dental  treatment  for  myself  or  
my  dependent  named  below  and  agree  to  pay  all  fees  and  charges  for  such  
treatment.    Payment  for  services  is  due  at  the  time  services  are  provided  unless  
other  financial  arrangements  have  been  approved  in  advance  by  our  staff.    We  
accept  cash,  check,  Visa  and  MasterCard.    We  also  work  with  CareCredit,  a  
company  that  provides  financing  for  dental  care.    A  fee  of  $30  will  be  charged  for  
all  returned  checks.    We  reserve  the  right  to  charge  a  broken  appointment  fee  for  
any  appointments  cancelled  without  48  hours  advance  notice.  
         We  will  assist  you  by  processing  all  your  claim  forms  at  no  charge  and  will  
accept  assignment  of  benefits  to  be  paid  directly  to  our  office.    In  this  situation,  
we  will  estimate  the  amount  of  coverage  and  determine  your  balance  due.    I  
understand  this  is  only  an  estimate  and  agree  I  am  responsible  for  any  balance  
due.  
         Accounts  more  than  sixty  days  past  due  will  be  assessed  a  service  fee  of  1.5%  
per  month  of  the  balance  due  with  a  $2.00  minimum.    Should  it  become  
necessary  to  place  my  account  with  an  outside  agency  for  collection,  I  agree  to  
pay  all  collection  fees.    Should  legal  action  be  filed,  I  agree  to  pay  any  costs  
deemed  proper  by  the  court.  
         I  have  read  and  understand  the  above  agreement.  
Patient  Name______________________________________________________  
Responsible  Party__________________________________________________  
Signature_________________________________Date____________________  


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