financial installment plan agreement

financial installment plan agreement

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Thank you for entrusting your dental treatment to Derry Village Dental Care. It is an honor for us to have been selected by you to do so. Our service philosophy is to be informed, honest, and fair. This Financial Agreement demonstrates our appreciation for your right to know ahead of time what our financial expectations are. Please contact our office of you have any questions or issues regarding our Financial Agreement.

We will happily submit your claims and accept assignment of dental insurance coverage as a favor if you agree to the following:


  • You must give us with an insurance card as well as the other necessary ‌information to verify your coverage and submit your claim.

  • Your insurance policy is a legally binding agreement between you, your employer, and the insurance provider. We are not a party to that agreement. We have a connection with you, not with your insurance carrier.

  • You are liable for your fees, not what your insurance company permits or considers "usual, customary, and reasonable," which varies from company to company.

  • We are not responsible for the accuracy of your insurance benefits, even if we estimate them. It is completely so on. Receiving our services implies that you assume responsiblity for payment regarless of our estimate.

  • All costs that are not covered by your insurance carrier are your responsibility, regardless or cause. Not all of the services we provide are covered by insurance. Benefits vary from one business to the next. Non-covered service fees, as well as deductibles and co-payments, are payable at the time of treatment.

  • As ESTIMATE of the benefits that the insurance company is acticipated to pay will be provided. Please keep in mind that this is just an ESTIMATE and that the real ocst may differ.


  • We offer a written/verbal estimate of costs, as well as payment that is required at each service visit.

  • We offer 0% interest on charges for treatments pain for in installments as long as payment is completed on time (T/C apply).

  • Cash, debit cards, Visa, and MasterCard are all accepted. If the insurance provider does not pay in whole (or as agreed upon) within 45 days, you will be responsible for paying the amount owing within two weeks.


  • It is your duty to guarantee that your insurance provider pays on time so that you do not incur Finances costs.

  • You agree to pay collection charges as well as reasonable legal fees incurred in trying to collect on this or any in this agreement are in Canadian dollars (CAD) (Canadian Dollars).

  • We realize that occasional financial difficulties may prevent you from paying your debt on time. In such cases, we urge you to report any such issues as soon as possible so that we may help you in managing your account within 3-4 business days by visiting in person or by phone, but this does not ensure leniency towards the agreement (T/C apply).