My signature authorizes release of my medical information and x-rays; and authorizes payment directly to Max S. Breazeal, D.D.S. upon completion of treatment.
I UNDERSTAND THAT DR. BREAZEAL IS AN OUT OF NETWORK PROVIDER AND THAT I AM RESPONSIBLE FOR MY INSURANCE DEDUCTIBLE AND CO-PAYS, SET OUT BY MY INSURANCE COMPANY, ON THE DAY SERVICES ARE RENDERED. I also understand that my dental insurance is a contract between me and the insurance company, not between the insurance company and Dr. Breazeal. I UNDERSTAND THAT AS A COURTESY TO ME, DR. BREAZEAL'S OFFICE WILL FILE MY INSURANCE, HOWEVER I AM STILL RESPONSIBLE FOR ALL DENTAL CHARGES. If the insurance company has not paid their portion within 30 days of being properly billed, as mandated by the insurance Commissioner of the State of Tennessee, I understand that the balance will become due and payable from me.
I understand that payment is due at the time services are rendered unless payment arrangements have been made and approved in advance. All unpaid balances will be subject to a finance charge after 90 days of 1.5% per month, which is an annual percentage rate of 14%. In the event we are forced to submit a delinquent account to a collection agency, I agree to reimburse any fees of any collection agency, which will be 33% of the debt, and all costs, and expenses, including reasonably attorney's fees we incur in such collection efforts, which will be added at the time the account is sent for collection.
I understand that as a courtesy to me, I will either be called, emailed or texted the day before the appointment to confirm. We are reserving that time exclusively for you, if for any reason you can no longer make your appointment please call within 24 hours to cancel or reschedule. Otherwise, you will be charged for a failed appointment fee. If I fail my appointment without giving 24 hrs notice a $25 FAILED APPOINTMENT CHARGE will be added to my account. If the appointment was for two hrs, there will be a charge for $50 added to my account.
All returned checks are subject to a $50 service fee. Any returned check must be resolved before any future appointments can be arranged.
I understand that responsibility for payment for dental services provided for my dependent or myself is MINE, due and payable at the time services are rendered.
It is important that I know about your Medical and Dental History. These facts have a direct bearing on your Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.