Dental Services Document

DENTAL SERVICES DOCUMENT

Parties

Patient Date of Birth:    Insurance Carrier:    Policy / ID #:

Recitals

WHEREAS, Provider is duly licensed and qualified to perform dental care and operates facilities at and maintains qualified personnel and equipment for the provision of dental services;

WHEREAS, Patient seeks diagnostic evaluation and dental treatment as described in this agreement and wishes to engage Provider to render such services commencing on under the terms set forth herein;

WHEREAS, the parties agree that payment, confidentiality, and the allocation of responsibilities shall be governed by the terms below.

Scope of Work

Provider shall perform the dental services described below in a professional manner consistent with applicable standards of care. Specific procedures, materials, and anticipated visits are to be set forth by Provider and agreed by Patient.

Payment Terms

Patient agrees to pay Provider for all services rendered in accordance with the fee schedule below. Patient acknowledges financial responsibility for all charges not covered by insurance.

Late Payment: If any payment due hereunder is not paid within days of the due date, Patient will be charged a late fee of percent per month of the outstanding balance or a flat fee of , whichever is greater.

Insurance Assignment: Patient authorizes Provider to submit claims to Patient's insurer and to receive insurance payments on Patient's behalf. Patient remains ultimately responsible for all charges irrespective of insurance determinations.

Term and Termination

This Agreement shall commence on the Start Date: and shall continue until the completion of the services described in the Scope of Work or until the End Date: , unless earlier terminated as provided herein.

Either party may terminate this Agreement for convenience upon providing days' prior written notice to the other party. Provider may terminate immediately for cause if Patient materially breaches payment obligations or fails to follow pre- or post-treatment instructions that jeopardize treatment or safety.

Confidentiality

Provider and Patient acknowledge that certain medical and personal information exchanged in connection with care is confidential. Provider will maintain the confidentiality of Patient's records and shall not disclose such information except as required for treatment, payment, healthcare operations, or as otherwise authorized in writing by Patient or required by law. Provider may disclose information to consultants, laboratories, insurers, or other providers who are involved in treatment or billing, subject to customary confidentiality safeguards.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to choice-of-law principles. Any dispute arising under this Agreement shall be resolved by the appropriate state or federal court located in the county where Provider maintains its principal place of business.

Entire Agreement

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations, and understandings, whether written or oral. Any amendment or modification must be in writing and signed by both parties.

Acknowledgment and Consent

By checking the boxes below and signing this Agreement, Patient acknowledges understanding of the proposed treatment, voluntary consent to the treatment, acceptance of financial responsibility, and receipt of privacy practices.

I consent to the proposed dental treatment and authorize Provider to perform the procedures described in the Scope of Work.

I acknowledge financial responsibility for charges not paid by insurance and authorize release of information necessary for claims processing.

I authorize Provider to release dental records and diagnostic information to other professionals or insurers as necessary for treatment or payment.

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