*              Your insurance is a contract between you and the insurance company.  We are not a party to that contract.  Dental insurance is not meant to be a pay-all option but meant to be an aid.  So please be aware that some and perhaps all of the services provided under your particular policy may be considered “Non-Covered Benefits”, above their “Usual and Customary Fee” or based on a set “Fee Schedule”. Your benefits are dependent on how much your employer paid for your particular plan.  If you have any questions regarding the details of your plan, we ask that you contact your company.  Regardless of what insurance pays, the final balance on your account is considered your responsibility.

*              Please understand that we can’t predict exactly what your insurance company will pay on a particular procedure or service and only an estimate can be determined of the charges based on the information your insurance company is willing to provide.   An annual deductible and any required co-payment on a particular service will have to be collected at the time of service, and can only be based on the general information released by your insurance company.

*              We will bill your insurance company as services are rendered.  Payment is expected within 45 days of that billing.  Any services not paid, within 45 day wait period, will become immediately due in full.  Any unpaid accounts that have elapsed 30 days past due date, will be subject to a billing and finance charge with a combined minimum of $5.00 per month.
               
*              Dental insurance usually covers Basic dental procedures.  Complex comprehensive procedures and Cosmetics are often times Non-covered services.

*              Occasionally, an insurance company will send a payment directly to you, the patient.  If this occurs, please bring the check and attached explanation of benefits to our office.

*              We will be happy to except your payment by check.  For all returned checks there will be a service charge of $25.00.

*              If for any reason we need to collect a balance, the patient or his/her legal guardian agrees to pay any and all costs of collections, not limited to or excluding , all collection agency fees in the amount of 35%, all attorney’s fees, court costs,  and bank fees, whether or not suit is filed.  In the event of any litigation relating to this policy, the exclusive venue shall be in Orange County, Florida.

•         If for any reason you are unable to keep your appointment, kindly give us 24 hours notice.  Without a 24  hour notice your account will be charged $50 per scheduled hour.

*              I authorize Dr. Paul Szott and/ or Dr. Arif Zaman  to perform any necessary dental treatment.  I understand there are possible risks and complications with any procedure.  I do not hold Dr. Paul Szott and/or Dr. Arif Zaman  liable for any complications that may arise during any dental procedure.

I Authorize Paul Szott, D.M.D. and/or Arif Zaman, D.M.D. to keep my credit card number on file so balances not paid by insurance within 45 days, may be charged to my credit card not to exceed the total treatment plan price. If we do not have a valid credit card on file you must pay entire balance at time of treatment including insurance portion.
Visa/MC card # __ __ __ __ -  __ __ __ __ - __ __ __ __ - __ __ __ __ exp.date __/__
Visa/MC card # __ __ __ __ -  __ __ __ __ - __ __ __ __ - __ __ __ __ exp.date __/__

I have had the opportunity to read this form and ask questions.  I understand and agree to the terms of the Financial policy.  Please have credit card and drivers license ready so we can photo copy it....

_______________________________________________________          ___________________
Signature of Patient or Legal Guardian                                                        Date
               
______________________________________________________  revised
Print Patients Name