I authorise the release of any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such dental care to third party payors and/or health practitioners. I authorise and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me.
I understand that my dental insurance carrier may pay less than the actual bill for services. I understand I am financially responsible for the full amount. I also understand that Compass Dental Care shall have the right to refuse any treatment at our discretion.
I understand that any major treatment requiring the services of an external laboratory will require a 50% deposit to be paid on or before the preparation appointment.
I will pay all fees for dental services on the day of treatment unless other arrangements have been formally agreed upon. I understand that if I have dental health insurance, I must present my health fund card on the day of treatment for electronic claims to be submitted. Claims cannot be submitted after the day of treatment.
Should the account be referred to a third party for collection, I understand that a finance charge of 1.5% per month (18% per annum) will be applied to all balances that remain outstanding for longer than 90 days. In addition, I agree to pay all costs of collection including but not limited to reasonable solicitor fees and court costs.
I understand that appointment deposits are non-refundable if I fail to provide at least 24 hours notice of cancellation.
I understand that treatment plans and associated fees provided are estimates only and are not guaranteed. Final costs may vary depending on the complexity of treatment required.
