Financial Agreement & Treatment Plan Acceptance

I understand that the cost above is an ESTIMATE based on the recommended treatment plan as of today. If the treatment plan changes (for example, because of conditions discovered during treatment), the cost may change. I will be informed before any change in cost.

I understand that any insurance estimate is based on information provided by my insurance company and is NOT a guarantee of payment. Where the practice is contracted (in-network) with my insurance plan, the practice will submit claims as required by that contract. Where the practice is not contracted with my plan, the practice may submit claims as a courtesy but I am responsible for following up with my insurer on payment. I am ultimately responsible for any balance not paid by insurance, regardless of the reason for non-payment (denial, exceeded annual maximum, ineligibility, etc.).

I authorize my insurance company to pay benefits directly to this practice for services rendered. I authorize the practice to release information to my insurance company necessary to process my claims, as permitted by HIPAA and the California Confidentiality of Medical Information Act.

If I am uninsured or am paying out of pocket (self-pay), I understand I have a right under the federal No Surprises Act to receive a Good Faith Estimate of expected charges before scheduled non-emergency services. If I receive a bill that is at least $400 more than my Good Faith Estimate, I may dispute the bill under federal law. The estimated cost above serves as my Good Faith Estimate unless a separate estimate is provided.

I understand I am financially responsible for all charges related to my care, including charges for services not covered by insurance. Payment for the patient portion is due at the time of service unless other arrangements have been made in advance.

I understand that appointments cancelled with less than 24 hours notice or missed without notice may be subject to a cancellation fee of $50 for routine visits or $100 for procedure visits (e.g., crown, extraction, surgical, sedation appointments). The practice will inform me of the applicable fee in advance. This fee represents a reasonable estimate of the practice's costs from a missed appointment (reserved chair time, staff time) under California Civil Code § 1671 and is not covered by insurance.

I understand that overdue balances may be referred to a third-party collections agency after the practice has provided me with reasonable notice and an opportunity to pay or arrange payment. If a court action is required to collect an unpaid balance, the prevailing party may be entitled to reasonable attorney fees and court costs as permitted by California Civil Code § 1717. Returned checks are subject to a $25 service charge as permitted by California Civil Code § 1719 (or the maximum amount permitted by law at the time). I understand my rights under the federal Fair Debt Collection Practices Act and California's Rosenthal Act (Civil Code § 1788).

I understand that if I cancel or discontinue treatment, refunds will be calculated based on services already completed and reasonable out-of-pocket costs the practice has actually incurred on my behalf at the time of cancellation (such as laboratory fees that have already been paid). Custom items in active fabrication (crowns, dentures, aligners, surgical guides) are non-refundable to the extent the practice has incurred the lab cost. The practice will provide an itemized accounting on request.