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I hereby agree to the following terms and conditions:

Effective January 1, 2008 due to the rising costs of billing and the slow speed with which insurance companies pay their claims; we must adhere to our financial policy. You should expect to pay for treatment (your portion, co-pay) each time you come to the office, unless previous financial arrangements have been made in writing. For your convenience, we accept PERSONAL CHECKS, CASH, VISA, MASTERCARD, DISCOVER, AND CARE CREDIT. For those who qualify, ask for more details.

Thank you for choosing Plainfield Family Dental Center as your dental health care provider. We are committed to provide quality dental care for you and your family. Your clear understanding of our financial policy is important to our professional relationship. Please speak with someone in our office if you have any questions about this policy.

We charge what is usual and customary for quality services that we provide. Your insurance company may have a sliding scale that may not reflect charges in this area. If we have direct contracts with your insurance company, we are bound by their fee schedule.

Your Insurance policy is a contract between you and your insurance company. You have certain responsibilities, such as paying your co-pay at the time of service and providing accurate, timely, and complete insurance information to this office. Please be sure we always have your current insurance, so that we may correctly file your claims.

We will be happy to bill your insurance for any balances due by your insurance, but you need to pay at time of service all your co-payments (deductibles, non-covered services, etc.) if you do not have dental insurance, you are required to pay in full at the time services are preformed.

Since we have no way to know all the individual insurance policies, it is your responsibility to contact your insurance company if you are concerned as to whether a charge is covered and what amount they will pay. We try to estimate your portion at the time of service, if there is a difference, you will be billed the balance. Outstanding balances billed to you will require a minimum payment of 30% of the balance due.

There is a 1.5% monthly late charge (18% annually) assessed on all balances after 30 days past due. Checks, which are declared non-sufficient funds, will be charged a $35.00 service fee. Also, the undersign agrees to pay a collection fee of 50% of the total owed when sent to collection. All accounts are sent to collections after 90 days past due. All attorney fees and court costs incurred by the creditor. All information provided is correct.

I have read the above financial policy for Plainfield Family Dental Center and I agree to the terms listed above.


All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.