In our continuing efforts of improve the efficiency of our financial operations, we wish to explain the management of our delinquent accounts. As the vast majority of our patients are responsible and reliable in reconciling their accounts in a timely fashion, this information may be unnecessary for the most of you. However, it is our responsibility to ensure that all our patients are aware of our financial policies. Accordingly, we ask that you read the following policy statement and indicate your understanding and acceptance of its terms by signing in the space indicated below.
You are expected to pay for services at the time they are rendered. If you have insurance, your payment portion is due at the time of service. If no payment is made on our account within thirty (30) days of the date of service, a past due statement will be mailed to the home address provided. If payment in full is not received within another thirty (30) days, your account will be placed with a law firm or collection agency for more formal collection efforts. Such a referral of our account may result in litigation if it is deemed necessary, and the individuals indicated below may be held liable for the principal, court costs and any attorney's fees awarded if the matter is placed in judgment. Any unpaid account will be charged interest at the statutory interest rate allowed by law in the state of Oklahoma and late charges of $10.00 per month if not paid in full within sixty (60) days of the date of service.
Signature (Guardian/Responsible Party)
Witness (Office Use)