Del Mar Laser Pediatric Dentistry & Orthodontics
12750 Carmel Country Rd. Suite #215San Diego, CA 92130
*IF CHILD, PROVIDE PARENT/GUARDIAN NAME(S) BELOW:
**IF STUDENT, PLEASE COMPLETE:
*Note: Some insurance plans do not cover this service; please check vour olan documents for details
CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS:
I authorize for my child. I agree to pay all the fees and charges for such treatment.
Financial agreement for dental treatment can be made pnor to the commencement of treatment. Dental benefit plans may cover only part of your dental treatment. It is understood that you are responsible for the entire balance of your account. The Contract of dental benefits is between the patient and the insurance company .. You are responsible for all services rendered, regardless if you have dental benefits or not. We bill your insurance company for you as a courtesy. PLEASE REMEMBER THE FINANCIAL OBLIGATION FOR DENTAL TREATMENT IS BETWEEN YOU AND THIS OFFICE AND NOT DEPENDENT UPON INSURANCE.
Authorization and Release
I authorize my dentist to release any information including the diagnosis and records of any treatment or examination rendered to my child during the period of such dental care, third-party payers and/or other heath care practitioners.
I authorize and request my insurance to pay directly to the dentist insurance benefits otherwise payable to Dr. Soudabeh Sharafi.
I authorize and request my dentist to use my signature on file for my signature on all dental insurance forms to expedite computer processing claims.
I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf of my dependents. If any insurance payment has not been received within 60 days the responsible party is billed immediately.
If I do not pay the entire balance within 60 days of the billing date, a late charge of 1.5% on the balance then unpaid and owed will be assessed to the bill for services rendered. I realize a failure to keep this account in good standing may result in you being unable to provide additional dental services except for dental emergencies where there will be prepayment. It is your responsibility to ensure your insurance company pays promptly so you can avoid finances charges. You agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.
I agree that I am the responsible party: Because a large percent of the population involves divorces situations it is the policy of this office to collect from the parent who brings the child in for dental services. We can give you a letter as a courtesy so the other parent can reimburse you for his/her percentage, but full payment must be paid at the time of the visit. This is standard for most businesses.
I acknowledge that I have read and agree to the above financial policy.