I hereby authorize Dr Bradley R Anderson to furnish information to insurance carriers concerning my treatment and I hereby assign to the dentist all payment for dental services rendered to myself or my dependents. I understand I am responsible for any amount not covered by the insurance.
In order to provide the best care at the lowest cost, payment is due at the time of service including insurance co-pays and deductibles. Unpaid balances will be subject to a service charge of 1.5% per month and annual rate of 18%. I agree to pay all collection, attorney and / or interest fees acquired if necessary to collect on this amount.