Assignment of Insurance Benefits, Payment Policy, and Payment Options
The policy of MCDental Care, PLLC is to be paid directly by your insurance company. By signing this form, you authorize direct payment to MCDental Care, PLLC and assume responsibility of all non-covered services
or provider charges that may exceed insurance payment.
Our payment policy is as follows:
Payment is required the day services are rendered.
Returned checks are subject to a $36 NSF fee and may be subject to an additional collection fee.
Balances over 30 days may be subject to additional collection action.
All accounts not paid within 90 days will be sent to a collection agency.
For your convenience, we offer several payment options. Please read the following information:
Cash or Check.
Visa, MasterCard, or American Express.
Interest-free or extended financing through CareCredit.
Credit balances on your MCDental Care, PLLC account are subject to reimbursement. A check will be issued by MCDental
Care, PLLC within thirty days of your request for a refund. However, processing/transaction fees will be deducted
from any refund in which credit balances occur due to a personal overpayment by credit card or CareCredit.
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice
depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on
the part of each patient must be determined before treatment. This dental office cannot render services on the
assumption that our charges will be paid by an insurance company.
A service charge of 1.5% per month (18% annum) on any unpaid balance will be charged to the patient on all accounts
exceeding 30 days past due, unless written financial arrangements are satisfied.
MCDental Care, PLLC can only estimate insurance payments and laboratory costs. All dental services not paid by
insurance are charged directly to the patient. Any unpaid balance, as well as attorney fees, court costs, and
collection costs incurred by collection and enforcement of a debt are the responsibility of the patient.
MCDental Care, PLLC updated cancellation policy: After hours, please contact Dr. Dziurgot on her cell (586.823.0422)
to reschedule. There will be a $35 fee for any cancellation within 2 business days. If two appointments are
cancelled or no showed within 2 business days notice within a 12 month period, MCDental Care, PLLC will place your
name on a call list. Three appointments without 2 business days notice within a 12 month period will result in
permanent dismissal from the practice.
Patient Acknowledgement and Consent for Services
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever
have any change in my health, I will inform the doctors at the next appointment without fail.
I have had full opportunity to read and consider the contents of this form and your Notice of Privacy practices. I
understand that by signing below, I am giving my consent to your use and disclosure of my protected health
information to carry out treatment, payment activities, and health care operations.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay
therefore the reasonable value of said services to said Doctor, or her assignee, at the time said services are
rendered. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a
waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be
I grant my permission to you or your assignee to telephone me at home or at my work to discuss matters related to
I have read the above conditions of treatment and payment and agree to their content.
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.