This is an agreement between Garner D. Morgan DDS, PA & Associates, as a creditor, and the Patient/Debtor named on this form.

In this agreement the words 'you', 'your', and 'yours' means the Patient/Debtor. The word 'account' means one has been established in your name to which charges are made and payments are credited. The words 'we', 'us', and 'our' refer to Garner D. Morgan DDS, PA & Associates.

Our goal in discussing financial arrangements relative to your dental needs include:

• To inform you of treatment alternatives, their respective advantages and/or disadvantages, and the consequences and/or risks of delayed treatment and/or non-treatment.
• We will discuss with you the costs of the dental treatment and alternative treatment. We will gladly answer your questions until you are completely satisfied.

Payment Options:
Unless we approve other arrangements, in writing, your co-payment and the payment for the balance of your statement is due at the time of service by Cash, Check, Visa, MasterCard, Discover or CareCredit. (CareCredit is an alternative financing program, which offers qualified applicants a flexible payment plan with interest free payment options)

Co-Payments:
Any co-payment required by an insurance company must be paid at the time of service. The co-payment is the estimated difference between the individual treatment cost and the insurance payment. In large cases (Crowns, Partials, Dentures, & Bridges) that involve an additional appointment for a delivery, the estimated co-payment is due before the start of the treatment. This allows us to keep our fees reasonable and process your dental laboratory work before your insurance claim is processed. (Most insurance carriers do not complete claims until the work is delivered.)

You are responsible for all fees that your insurance company has not paid within a 60-day period from when treatment is begun. You will be expected to pay the full amount due.

Charges to Account:
If after your insurance claim has been processed, and you have a balance on your account, we will send you a statement. It will show the balance, any new charges to the account, amount past due, and insurance pending if applicable. We reserve the right to cancel the privilege to make charges against your account at any time. Further visits would need to be paid at the time of service.

Past due accounts:
If your account becomes past due, over 90 days, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all of the collection cost, which is incurred. If we have to refer collection of the balance to a lawyer, you agree to pay all legal fees plus all court costs. In a case suit you agree to have St. Mary's County, Maryland as the venue.

Returned Checks:
There is currently a $35 fee for any checks returned by the bank. More than one returned check will require patients to make payment by Credit Card or Postal Money Order.

Missed Appointments:
The second time a patient misses a confirmed appointment or cancels with less than 24 hours notice a letter will be sent. Patients with three missed appointments may be asked to transfer their records to another doctor. In the case of new patients who do not show, it is at the discretion of the office on whether to reschedule or deny acceptance of the patient into the practice.

Credit History:
You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the right to report delinquent accounts to credit agencies such as Experian, Equifax, and TransUnion.

Dental Insurance:
We are happy to assist you in receiving your maximum dental insurance benefits. Insurance is a contract between you and the insurance company. We are not a party to the contract, in most cases. We will bill your insurance company as a courtesy to you. Although we may estimate what the insurance company may pay, it is the insurance company that makes the final determination of eligibility. For dental treatment that you consent to, you agree to pay any portion of the charges not covered by insurance.

We accept most major PPO insurance plans. We will submit to your insurance company on your behalf for PPO plans that we do not participate. Patients with certain insurance may be required to present payment in full at time of services. You will be given a doctor's walkout form for you to submit to your insurance company for reimbursement.

Insurance Estimates:
Our office is only able to estimate your reimbursement. We make every effort to be 100% accurate with your estimate, but we cannot guarantee that your respective carrier will make payments. Please remember that our agreement is with you, not your insurance company. If your insurance company denies payment, or pays less than estimated, you must remember that dental insurance is designed to offset the costs of your dental treatment. It is unusual for all of the charges to be paid for by the insurance. For an exact statement of benefits, a predetermination form can be sent to the insurance company. The insurance company will generally send an explanation of benefits stating their payment and your co-payment responsibility within 4-6 weeks.

Cosmetic Dentistry & White Fillings:
Cosmetic and elective procedures such as Invisalign, tooth whitening, implants, and veneers are generally not covered by most dental insurance plans. Payment prior to the time of service is expected in full, unless other arrangements have been made in writing. Most insurance companies will pay approximately 80% of the cost for amalgam (silver fillings) on posterior (molar and bicuspid) teeth. If a white, tooth colored resin material is used, the insurance company usually pays the percentage based on the cost of the amalgam, silver filling. However, some carriers do not cover white resin fillings. Please ask our business staff if you have any questions.

Confidentiality Waiver:
You understand that if your account is submitted for collection, to an attorney, or for litigation in court, your account information may become a matter of public record.

Fee Guarantees and Nonpayment Procedures:
The estimated fees we provide for dental services are guaranteed for 90 days, providing no change in your dental insurance company. If treatment is not begun within 90 days of the estimate date, cost of dental treatment could vary. Once dental treatment has begun, changes in the anticipated treatment plan may be required, depending on oral conditions encountered. You will be informed if this occurs and given the options of continuing treatment, changing treatment, or canceling treatment.

By executing this agreement, you are agreeing to pay for all services that are received.

I have read the above mentioned financial policy and have had the opportunity to ask questions regarding my financial information in relation to my dental treatment.

Patient's Name
Responsible Party

Signature