PAYMENT AGREEMENT
I agree that I am financially responsible for all services provided by Hollywood Perfect Smile and that payment is due and payable to the Practice at the time services are rendered and that health, dental, and accident insurance policies are arranged between my insurance policy and me. I agree to pay all deductibles and co-pays at the time of service. I agree that my insurance coverage, my co-pay, or deductible will be based on the primary coverage. I understand that while the practice will file claims with my insurance company on my behalf, I remain responsible to the practice for what is not covered by my insurance providers. I also understand that if the Practice cannot verify insurance benefits are eligible for me prior to treatment, I will pay In full for the treatments. I understand that the practice may charge a late fee of $35.00 if the payment on my account has insufficient funds by the due date, this amount will not exceed the maximum amount permitted by law for each returned check, and any fees for missed/canceled appointments without 24-hour advanced notice. I agree to pay for any expenses or costs relating to the collection proceeding, including court fees, attorneys, or collection agencies in case they are still balanced due to the treatments received at the practice. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable.
