Northgate Dental Financial Alliance

WE BELIEVE THE DISCUSSION OF FINANCIAL ARRANGEMENTS CREATES AN UNDERSTANDING AND A PARTNERSHIP THAT HELPS YOU ACHIEVE YOUR GOALS FOR YOUR DENTAL HEALTH.

We make every effort to work within your budget. Our role is to help you understand your options for treatment and to provide you with excellent service. Our team will work with you to determine financial arrangements that work for you.
We accept Visa, Master Card, Discover, American Express, Cash and Bank Certified Check.
Credit check is required for in office financial payment plans, and is not applicable for amounts less than $1,500.00 and these amounts must be paid at time of service.

PAYMENT FOR SERVICES

We require all balances to be paid in full at the time of service.

Patient Name*
First Last
Social Security #*
Driver's Lic #*
Driver's Lic State*
Driver's Lic Exp.*
MM slash DD slash YYYY
I agree to pay in full at time of service. Northgate Dental will reimburse patient if insurance company pays.*
- Yes
RESIDUAL BALANCES MAY BE ROLLED ON TO*
- Care Credit® or SpringStone® Financial Credit Cards
- Guarantee any amount not covered by insurance with Credit Card, Cash, Check
- Yes, I authorize Northgate Dental to seek credit on my behalf. This is needed to have the opportunity to pay the day of service rather than pre pay for some appointments.
- No, I do not wish to have any credit check or in office payment plans. I agree to prepay as needed for all specified appointments.
INSURANCE
As a service to our patients we file all dental insurance claims electronically. We will make every effort to insure that you receive your full benefit and follow up with your insurance company as needed. Please be aware that certain insurance companies are more difficult to work with than others. As a courtesy we will file your claim up to three times, and after 90 days the balance becomes your responsibility. Insurance benefits are a matter between you and your insurance company, please be knowledgeable about your benefits and coverage.*
- I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to Northgate Dental or Joshua D. Carter DDS PLLC.
- I agree to be responsible for all charges for dental services and materials unless prohibited by law. To the extent of law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim. I understand all fees are estimates only.
- I understand if my account becomes delinquent, it may be forwarded to an outside collection agency without notice. If this happens, I will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court cost, attorney fees and collection agency costs.
Electronic Signature

Please type in your name, authorizing this form and that all information is correct.
Date*
MM slash DD slash YYYY
CAPTCHA