FINANCIAL AGREEMENT

We offer two different options in which your dental treatment can be paid. Please initial beside your preference of the following options.

Option One-You may pay in full at the time of service; after which we will submit your dental claim on your behalf and inform the insurance company to issue the reimbursement directly to you.

Option Two –Direct billing from Cool Smiles Children’s Dentistry asking the insurance to issue their payment directly to the dental office. Assignment of benefits from your insurance company will require a valid VISA OR MASTERCARD to be left on file. Our office will not allow any balances to extend over 60 days from the date of service

All dental procedures in our practice are treatment planned based on the dental needs of the individual patient; not limited to the benefits extended by their insurance providers. It is your responsibility to know your insurance details such as benefit maximum and frequency limitations. Neither the dental office nor its employees will assume responsibility of knowing dental coverage details.

Minor Patients: The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any expectation. The office will not attempt to collect payment from a parent that is not present in the office at that visit. If the divorce decree requires the other parent to pay all or part of the treatment costs it’s the authorizing parent’s responsibility to collect from the other parent.

Credit Card Authorization

I authorize Cool Smiles Children’s Dentistry to keep my signature and card information on file and charge my VISA/VISA DEBIT OR MASTERCARD account for the following.

Balances of charges not paid by my insurance immediately after receiving payment from the insurance company. Individual phone calls from the office will NOT be made before the card if charged for expenses unless the amount should exceed $200.00. A receipt will be issued by mail or e-mail.

All outstanding balances on my family account if not paid within 60 days by my insurance.

Charges accrued as a result of broken appointments or short notice cancellations within reason. This fee is a nonrefundable $50.00 per individual for each failed appointment; $150 for dental treatment visits per child. Multiple occurrences will result in dismissal from the practice.

This authorization will be held for each client listed below until otherwise notified to our office in writing stating otherwise.

Patient name(s):
Cardholder Name:
Cardholder Address:
Account number
Expiry Date:
Verification Code:

(last 3 digits on the back of the card)

Cardholder signature:
Today’s Date: