financial agreement form fillable .pdf
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
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
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.
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