Auto Notes Samples

This Office Manager resource provides detailed examples of Auto Notes to use in your office.

Auto Notes Samples


This agreement is good for each patient and is valid until you request an updated financial agreement. Payment arrangements are required at the time of scheduling your appointment. We offer the following payment options (please choose one):

______ PAYMENT AT THE TIME OF SERVICE (We accept Cash, Check, MasterCard, Visa, Discover and American Express) ** entire out of pocket estimate for services rendered is due the day of treatment. _____ 5% PREPAYMENT DISCOUNT FOR PAYMENT IN FULL WITH CREDIT CARD (this is offered for payments Of The Full Out Of Pocket Amount for the Entire Treatment plan 3 days prior to the first appointment)

_____ 10% PREPAYMENT DISCOUNT FOR PAYMENT IN FULL WITH CASH/CHECK (this is offered for payments of The Full Out Of Pocket Amount for the Entire Treatment plan 3 days prior to the first appointment)

_____ INTEREST FREE FINANCING – (up to 12 months interest free financing depending on amount financed upon approval from either CareCredit or Lending Club). Financing Application and Approval needs to be done 3 days prior to the scheduled appointment. This is an estimate only of treatment diagnosed based on clinical and x-ray examination. You have been presented with the risks, benefits and alternatives of this treatment. All your questions have been answered.

PLEASE NOTE: The total fee charged is your obligation. When final payment has been received by your insurance company, we will reconcile the account and bill or refund you any difference. If your insurance carrier has not paid within 45 days following a claim, the entire balance is due and payable at that time. By signing below, I understand that this is only an ESTIMATE and that there may be a balance due after insurance pays what I am responsible for. I hereby certify that I have fully read the above and agree with all the terms and conditions.

INSURANCE BREAKDOWN – Frequencies & Limitations

View the complete document and print out a copy for your office below!
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