Please initial option 1, 2 or 3 and sign at the end. Thank you.
· For your convenience this office may release treatment related information to your insurance company and receive payments directly from them. We require a copy of the valid US driver’s license of the parent/guardian bringing the children to the appointments.
· Estimated remaining balance is due at the time of the appointment.
__ 1. In order for us to bill your insurance company on your behalf, we require a social security number of the primary caregiver who brings children to the appointments and is responsible for signing this form.
Your social security number is______
___2. If you do not wish to provide us with your social security number, you agree to be responsible for the payment in full at the time of the visit. We can submit claims on your behalf and you can get reimbursement from your insurance company directly.
___ 3. Alternatively, you can provide us with a copy of your credit card to keep on file. Any remaining balance after the insurance payment will be charged to the card. You will receive a statement in the mail detailing these charges. The credit card agreement will be updated at 6 months visits.
· In the event of the unpaid balance occurring or your account past 60 days of the date of service,
1% finance charge per month (12%APR) will be applied to that amount. The account will be turned over to collections and you will be responsible for the associated fees and court costs should they occur.
· If the balance gets collected through the collection agency, we will no longer bill your insurance on your behalf for the future visits. You will be responsible for the payment in full at the time of the visit.
· A $50 rescheduling fee will be charged to your account if the appointment is broken without a 48 hour notice.
· Treatment plans may change and you will be responsible for the work actually done.
Name of the child: Date of birth:
Parent/Guardian name: Signature:
Relationship to the minor: Date: