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Responsible Party

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Dental Insurance Information

Subscriber's Name
Insurance Company Address
I understand the responsibility for payment of dental services provided in this office for myself and my dependents is mine. It is due and payable at the time services are rendered. Dr. Malone's office will file all dental claims less than $200.00. All insurance co-pays and deductibles are due at the time of service. Dr. Malone's office will assist me by providing all the information necessary for me to file my dental claims over $200.00. I further understand that a 1.75% finance charge (21% annually) or a $2.00 billing charge (whichever is greater) will be added to any balance over 90 days. In the event of default, I promise to pay legal interest on the indebtedness, together with such collection costs and attorney fees as may be required to effect collection of this note.
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