Form 3 of 3
We at Dr. Michael D. Stern's office have made a commitment to provide all of our patients with high quality outpatient health care. It is a commitment which we take seriously. In return, we expect those whom we serve to be fair and to see that we are paid for those services in a timely manner. We offer several payment options for the convenience of our patients. You will find these listed in the New Patient folder that you were given and also at the front desk in our office. Please understand that your dental insurance is a contract between you and the insurance carrier, not between the insurance carrier and Dr. Stern. You are responsible for all fees incurred, irrespective of applicable insurance coverage. All balances over 90 days will be charged 2% interest, monthly. I understand the financial policy and agree to comply with it. I understand that I am responsible for ALL fees regardless of insurance coverage. I also understand that, from time to time, credit information may be obtained from appropriate sources.
(Your digital signature (full name) is as legally binding as a physical signature.)
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