Financial Agreement for Hamid Zehtab, DMD
This agreement is to inform you or your financial obligation to our practice.� We are committed to providing you with the most comprehensive dental care using only the highest quality materials and technology available in the market today.� We are also committed to providing you with the most up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health.� This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing administrative costs.
All charges you incur are your responsibility regardless of your insurance coverage.� We must emphasize that as your dental care provider our relationship is with you, not with your insurance company.� Your insurance policy is an agreement between you, your employer and the insurance company.� Our practice is not a party to that agreement.� If payment from your insurance company is not received within 60 days from your date of service, you will be expected to pay the balance in full.�
As a courtesy to you we will process all of your insurance claims.� You may direct your insurance company to pay your benefits directly to our practice by signing the authorization on the Assignment of Benefits Agreement.� Your estimated co payment for treatment, which is the amount not covered by your insurance company, is due at the time treatment is rendered.� Your estimated co payment may be adjusted depending upon the final reconciliation of the insurance payments.� ��
Our practice accepts cash, personal checks, Visa and MasterCard.� Third party financing is available upon request and approval.� Returned checks and balances older than 60 days will be subject to a collection fee and finance charges at the rate of 1.5% per month (18% annually).� I understand that if my account reaches collection status (90 days) and I make no effort to pay off my account will be assigned to a collection attorney or agency. If Dr Zehtab must take additional steps to collect my account, I will pay ALL cost of collection, including court cost and attorney�s fees incurred by Dr Zehtab.
Additionally we pre-plan and prepare for your visit and we expect you to do the same.� Your appointment time has been reserved for you.� When time is lost due to last minute cancellations and/or no shows, other patients in need of treatment cannot be seen and your treatment is delayed.� Should any scheduling changes occur we require at least 48 business hours notice to avoid a $50.00 per half hour cancellation fee.
We consider all appointments confirmed when they are made.� As a courtesy, we make every effort to remind patient by telephone or email prior to their appointment but please do not depend on this courtesy.� �If we are unable to speak with you directly, your appointment card will serve as your confirmation and implies your obligation to be present at that prearranged date and time.�
Please do not hesitate to ask if you have any questions or concerns regarding this financial agreement.� We are committed to providing you with the ultimate experience in dental care.