Financial Agreement

Payment: Payment is expected in full for each appointment as services are rendered. Payment options are:
  • Cash
  • Credit Card (Mastercard, Visa, American Express, Discover)
  • Checks
Dental Insurance: Insurance is a contract between you and your insurance company. There is no direct relationship between our office and your insurance company. Your insurance benefits are determined by the type and design of plan chosen by you and/or your employer. We are not party to this contract. We have no control over the terms of your contract, the method of reimbursement, or the determination of your benefits. Some and perhaps all of the services can be defined by your insurance company as “not covered”, “denied”, or “over UCR”. We will file your primary dental insurance claims as a courtesy to you. We do not guarantee payment and are not responsible for providing you with the plan limitations, exclusions and provisions determined by your insurance company. You agree to pay any portion of the charges not covered by your insurance company. WE DO NOT FILE SECONDARY INSURANCE. We can provide a detailed receipt for all completed procedures.
Missed Appointment Fee: Our office requests 24 hours (one business day) notification if you are unable to keep your scheduled appointment. If less than 24 hours notice is given, a $25 charge per child will be charged to your account. Patients with three missed appointments may be asked to transfer their records to another doctor.
Emergency/After Hours Appointments: If your child is seen for an emergency visit after our regular business hours, an “after hours” fee is charged in addition to any treatment on that visit. All emergency treatment must be paid in full at the time of service.
Finance Charge: A finance charge will be added to your account for any balance over $50 that is unpaid within (30) days of the date of service. The FINANCE CHARGE will be computed at the rate of (1%) per month.
Returned Checks: There is a fee ($40) for any checks returned by the bank.
Monthly Statement: If you have a balance on your account, we will send you a monthly statement. It will show the previous balance, any new charges to the account, finance charge, if any, and any payments or credits applied to your account during the month. Professional fees are the responsibility of the parent or guardian authorizing treatment. We cannot send statements to other persons.
Past Due Accounts: If you account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection costs which are incurred.
Divorce: In case of divorce or separation, the responsible party prior to the divorce or separation remains responsible for the account. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent’s responsibility to collect from the other parent. We cannot be the go between for two people. Please discuss keeping a credit card on file with the front desk if needed.
EffectiveDate: Once you have signed this agreement, you agree to all of the terms and conditions herein and the agreement will be in full force and effect.
This is an agreement between, Dr. Julie Longoria & Dr. Stephen Chen and associates, and the Patient/Debtor named on this form. In this agreement the words “you”, “your” and “yours” means the Patient/Debtor. The word “account” means the account that has been established in your name for your child to which charges are made and payments are credited. The words “we”, “us”, and “our” refer to Dr. Julie Longoria & Dr. Stephen Chen and associates.
Patient First Name:
Last Name:
Parent/Guardian First Name:
Last Name:
Patient/Parent/Guardian E-Signature: