Pre-Authorized Debit Agreement

Patient's Name Patient's Name First Last
Patient's Date of Birth Patient's Date of Birth / MM / DD YYYY
Name of Parent (Financially Responsible Party) Name of Parent (Financially Responsible Party) First Last
Parent's Date of Birth Parent's Date of Birth / MM / DD YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Cell Phone Number Cell Phone Number - ### - ### ####
Email
Total Pre-Authorized Debit Amount (full fee minus insurance and downpayment) $ Dollars . Cents
This is the expected amount of insurance. Any amount that cannot be direct billed to the insurance will be added to your account.
Monthly payment amount $ Dollars . Cents
Number of monthly payments
Preferred Billing Date

Preferred Billing Date 1st of the month 15th of the month
* INFORMATION REGARDING FEES:

The total fee is comprised of an appliance fee (0% HST) and a treatment fee.

I agree to pay the above fee for the services provided by Dr. Liliya MacKenzie Professional Corporation and acknowledge that this fee is based on the professional fees, appliance fees (0%tax) and work done, and not on the duration of treatment.

The treatment time and the length of the payment plan are independent of each other. If the treatment is shorter than the estimated treatment time, I understand that I am still responsible for the entire value of the contract.

* INFORMATION REGARDING INSURANCE:

I understand that in consenting to this request for pre-determination that there will be communications between my orthodontist and my third party payer to determine whether the procedure is covered. I understand that the third party payor may require information from my dental records, including, but not limited to x-rays, photos, etc.

I hereby authorize my orthodontist to release all reasonable and pertinent information contained in my dental records requested and required by my third party payor to access coverage for the proposed procedure.

* INFORMATION REGARDING DIRECT BILLING INSURANCE:

If the expected amount from the insurance is not received, the remainder will be charged to your account. If you have insurance, please be advised that it takes a minimum of 6 months to process all the payments through your insurance company. If there is a change in your insurance, you must notify our office immediately. If we are not notified, you may not be able to receive your insurance payments in a timely manner. We will not be able to direct bill your new insurance company, but we’ll provide claims for the payments you have made to our office. If the insurance is direct billed (ie. our office is supposed to receive the payments) and you received a payment from your insurance company, you must bring the cheque to the office since the amount will be charged to your account immediately.

* INFORMATION REGARDING BANKING POLICIES:

* The minimum monthly payment that can be processed through cash, debit or credit is $200. If the account is split between two parties, each party will be charged the minimum payment.

* For payments by cheque, a $30 administrative fee will be charged for each cheque with insufficient funds. A $30 administrative fee will be charged for holding a cheque past its due date or for holding a credit card payment or for a declined credit card payment. Active treatment will be suspended on patients whose accounts are severely past due.

* A 2% monthly interest fee (24.3% per annum) will be charged on all accounts 30 days past due.

* Should the account be placed in collections, you will be responsible for the actual collection costs and expenses including collection agency costs

* INFORMATION REGARDING FEES:

The total fee is comprised of an appliance fee (0% HST) and a treatment fee.

I agree to pay the above fee for the services provided by Dr. Liliya MacKenzie Professional Corporation and acknowledge that this fee is based on the professional fees, appliance fees (0%tax) and work done, and not on the duration of treatment.

The treatment time and the length of the payment plan are independent of each other. If the treatment is shorter than the estimated treatment time, I understand that I am still responsible for the entire value of the contract.

* INFORMATION REGARDING INSURANCE:

I understand that in consenting to this request for pre-determination that there will be communications between my orthodontist and my third party payer to determine whether the procedure is covered. I understand that the third party payor may require information from my dental records, including, but not limited to x-rays, photos, etc.

I hereby authorize my orthodontist to release all reasonable and pertinent information contained in my dental records requested and required by my third party payor to access coverage for the proposed procedure.

* INFORMATION REGARDING DIRECT BILLING INSURANCE:

If the expected amount from the insurance is not received, the remainder will be charged to your account. If you have insurance, please be advised that it takes a minimum of 6 months to process all the payments through your insurance company. If there is a change in your insurance, you must notify our office immediately. If we are not notified, you may not be able to receive your insurance payments in a timely manner. We will not be able to direct bill your new insurance company, but we’ll provide claims for the payments you have made to our office. If the insurance is direct billed (ie. our office is supposed to receive the payments) and you received a payment from your insurance company, you must bring the cheque to the office since the amount will be charged to your account immediately.

* INFORMATION REGARDING BANKING POLICIES:

* The minimum monthly payment that can be processed through cash, debit or credit is $200. If the account is split between two parties, each party will be charged the minimum payment.

* For payments by cheque, a $30 administrative fee will be charged for each cheque with insufficient funds. A $30 administrative fee will be charged for holding a cheque past its due date or for holding a credit card payment or for a declined credit card payment. Active treatment will be suspended on patients whose accounts are severely past due.

* A 2% monthly interest fee (24.3% per annum) will be charged on all accounts 30 days past due.

* Should the account be placed in collections, you will be responsible for the actual collection costs and expenses including collection agency costs I hereby certify that I have read and received a copy of the above disclosure statement.
Bank Account Information
Account Type

Account Type Checking Savings
Deposit Account Number
Maximum of 16 digits allowed. Currently Entered: 0 digits.
Branch Transit Number
Must be between 4 and 5 digits. Currently Entered: 0 digits.
Financial Institution Number
Must be 3 digits. Currently Entered: 0 digits.
Financial Institution Name
You, the Payor, authorize Dr. Liliya MacKenzie PC to debit the bank account identified above for the monthly payment amount on the 1st or the 15th every month or the next business day.

You, the Payor, may revoke your authorization at any time in writing, subject to providing notice of 30 days. To obtain a sample cancellation form, or for more informatin on your right to cancel a PAD Agreement, contact your financial institution or visit www.cdnpay.ca.

You have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on your recourse rights, contact your finacial institution or visit www.cdnpay.ca.

You, the Payor, authorize Dr. Liliya MacKenzie PC to debit the bank account identified above for the monthly payment amount on the 1st or the 15th every month or the next business day.

You, the Payor, may revoke your authorization at any time in writing, subject to providing notice of 30 days. To obtain a sample cancellation form, or for more informatin on your right to cancel a PAD Agreement, contact your financial institution or visit www.cdnpay.ca.

You have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on your recourse rights, contact your finacial institution or visit www.cdnpay.ca. I understand and agree to the above statement
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Pre-Authorized Debit Agreement

Pre-Authorized Debit Agreement

Bank Account Information