INITIAL EACH FIELD


APPOINTMENTS POLICY: Please kindly give 48 hours advance notice if you cannot keep your appointment. There is a $50 fee per 60min that will be charged to your account for the time reserved for appointments missed or cancelled late without 48 hours advanced notice given. If you are late to an appointment, please understand that your appointment may be shortened or rescheduled.

PAYMENTS: Payment for the patient’s portion is due at the time of service and to be addressed to Samira Davis, DDS or the DBA: Davis Family Dentistry. Patient portions include estimated patient portions deductibles and co-pays. Insurance estimates are provided as a courtesy, however are in no way a guarantee of coverage. In the event that your insurance carrier pays less than the estimated amount, then you, the patient and/or guarantor, is responsible for the full unpaid balance. Pre-determinations are performed upon request, however are not a guarantee of benefits. We accept cash, check, MasterCard and Visa.

INSURANCE: Insurance is NOT a guarantee of payment. Please remember that your insurance policy is a contract between you, your employer and insurance company. Not all services are covered benefits in all dental contracts. It is your responsibility, as the patient, to review and know your policy, its coverage and limitations, as it is an agreement between you and your insurance company. Our staff will do their best to assist you in coordination of benefits, however it is ultimately your responsibility to keep track of benefits and remaining benefits throughout the benefit year from your insurance. We must emphasize that as dental care providers, our relationship is with you, not your insurance company. While the filing of insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered.

FINANCE CHARGE: Outstanding balances over 90 days are subject to a 1.5% per month, 18% APR, $1.00 Minimum.

PATIENT AUTHORIZATION: I have read, understand, and agree to the terms and conditions of this financial agreement. I agree to abide by the terms of these financial policy. I authorize this office to release information, relating to my dental care, to my insurance company and authorize payment of benefits to be made to Samira M. Davis, DDS, PS – DBA Davis Family Dentistry. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account. I authorize and give consent for dental treatment of the patient named above and agree to pay all fees and charges for such treatment and services rendered. I understand as the parent and/or legal guardian of the minor receiving dental care at this office, I am ultimately responsible for all payments or fees for dental services rendered to the minor in my care. I agree that this authorization shall remain valid until cancelled by me in writing. FINANCIAL AGREEMENT FOR: Samira M. Davis, DDS, 523 Kirkland Way, Kirkland, WA 98033 425.822.3505 www.DentistryKirkland.com