Payment Policy Acknowledgement

CASH:  Payment in full at the time of treatment.

INSURANCE: Co-payment and/or deductible payment of insurance coverage is due at the time of treatment.  However, if there is no payment from your insurance company to our office within 60 days, you are responsible for the balance in full at that time.  Excellent Dental Care Center and EDC are not able to negotiate with your insurance company on your behalf.

CANCELLATION AND NO SHOW POLICIES:

1. Cancellations should be made at least 48 hours before the appointment time (weekends and holidays are not counted).

2. Any cancellation without 48 hours notice or no show is subject to $50.0 charge.  If the patient refuses to pay it, he/she will have to wait 1 to 3 months to be seen again and/or to be terminated, which is depending on the length of the failed appointment.

3. Patient with 3 failed appointments is subject to automatic termination.

TERMINATION:

Patient has 15 days from the last cancelled or no-show appointment for his/her emergency ONLY at Excellent Dental Care Center and EDC and patient to be encouraged to find other dentist to finish hi/her dental treatment.

As patient, or legal guardian of minor patient, i agree to pay for all services rendered in accordance with the terms and conditions st forth in the financial policy of the office.  After 60 days, all accounts are subject to finance charge of 1 1/2 % of the unpaid balance, which is an Annual Percentage Rate of 18%.

I (We) hereby authorize Drs. Nguyen and associates at Excellent Dental Care Center and EDC, to furnish my (our) insurance company (or companies) all information required concerning my (our) dental care.  I hereby assign to Drs. Nguyen and associates, all payments to which I (we) may be entitled for dental expenses, and do hereby direct that payment for such expenses to be paid directly to Drs. Nguyen and associates and/or Excellent Dental Care Center and EDC.