Thank you for filling out the patient questionnaire. Now, please take your time to fill out the following account information. Thank you.

Patient Account Information Form

We would like to remind all patients that ACC does not pay the full amount claimed in any procedure. For patients who receive ACC assistance, there will always be a shortfall that we have to pass on to the patient.

To ensure that you have been given this information we would ask that you sign below. This form will then be scanned into you personal dental records.

I understand the procedures that are involved in ACC payments.

Patient is not responsible for payment of accounts, then the person named below agrees to guarantee payment:

Guarantee

If I execute this agreement as the person responsible for payment on behalf of the Patient I guarantee the due and punctual payment of all monies payable under this agreement.

This Guarantee and Indemnity shall constitute an unconditional and continuing guarantee and indemnity and accordingly shall be irrevocable and remain in full force and effect until the whole moneys owing to the Dentist by the Patient and all obligations

 

Payment Terms and Conditions

1. "Dentist" shall mean Supreme Dental Concepts T/A Tennyson Dental Centre.

2. "Patient" shall mean the Patient or any person (or persons) that agree herein to be liable for the debts of the Patient on a principal debtor basis.

3. Time for payment for the Services shall be of the essence and will be stated on the invoice. If no time is stated then payment shall be on delivery of services.

4.1 At the Dentist's sole discretion, payment for approved Patients or Persons responsible for the Account shall be made by installments in accordance with the Dentist's payment schedule.

4.2 Interest on overdue invoices shall accrue from the date when payment becomes due daily until the date of payment at a rate of 2.5% per calendar month and such interest shall compound monthly at such a rate after as well as before any judgment.

4.3 If the Patient defaults in payment of any invoice when due, the Patient shall indemnify Dentist from and against all of Dentist's costs and disbursements including on a solicitor and own client basis and in addition all the Dentists nominees costs of collection.

4.4 If any account remains overdue after thirty (30) days then an amount of the greater of $20.00 or 10.00% of the amount overdue (up to a maximum of $200) shall be levied for administration fees which sum shall be immediately due and payable.

5.1 The Patient and the Guarantor/s (if separate to the Patient) authorizes the Dentist to:

(a) collect, retain and use any information about the Patient, for the purpose of assessing the Patient's creditworthiness or marketing products and services to the Patient; and
(b) to disclose information about the Patient, whether collected by the Dentist from the Patient directly or obtained by the Dentist from any other source, to any other credit provider or any credit reporting agency for the purposes of providing or obtaining a credit reference, debt or collection or notifying a default by the Patient.

5.2 Where the Patient is an individual the authorities under (clause 5.1) are authorities or consents for the purposes of the Privacy Act 1993.

5.3 The Patient shall have the right to request the Dentist for a copy of the Information about the Patient retained by the Dentist and the right to request the Dentist to correct any incorrect information about the Patient held by the Dentist.

 

I certify that the above information is true and correct. I authorize the use of my personal information as detailed in the Privacy Act clauses 5.1-5.3 (above). I have read and understand the PAYMENT TERMS AND CONDITIONS (above) which form part of, and are intended to be read in conjunction with this Patient Information Form and agree to be bound by these conditions.