2 of 2
Collecon of Delinquent Account Terms: Failure to pay my balance within 30 days from any Date of Service is
considered a delinquent account and may result in fees and interest being added to my Account Balance
as follows:
1. Delinquent accounts 30 days past due will accrue interest at a rate of 24% per annum, unl paid in full.
2. An account delinquent with any outstanding balances for 60 days may be forwarded and assigned to a
collecon agency at the paent’s expense.
3. Any delinquent account assigned to any collecon agency will be charged a collecon fee, which upon
assignment becomes the due and owing Account Balance. COLLECTION FEES ARE BETWEEN 40% and
50% OF THE BALANCE OWING AS OF THE DATE OF SERVICE, AND WILL BE ADDED TO THE OUTSTANDING
ACCOUNT BALANCE WITH OR WITHOUT SUIT.
4. If legal acon is required to collect this account, in addion to any Account Balance, I/We or the
Paent’s representave who signs below agrees to pay interest as set forth herein, plus all costs
associated with such collecon acvity, including but not limited to all collecon agency fees as set
forth herein as part of the Account Balance, plus any and all aorney fees, court fees, skip tracing fees
and costs in addion to any miscellaneous fees the court of jurisdicon may award.
Collecon Excepons and Exempons: allowed charges under Medicare Title XIX (Nevada
Medicaid) contracts.
Returned Checks or Disputed Credit Card Payment: There is a fee of $35.00 for any returned check for
insufficient funds. If a credit card payment is disputed and payment is wrongfully taken back from Desert
Perinatal Associates by your credit card company, a $40.00 fee will be add to your account. These amounts
may change at any me.
Assignment: If this account becomes delinquent, I/We hereby authorize this office to assign this account
and/or release any necessary informaon to any third party collecon agency. Addionally, if my account is
assigned to any collecon agency, I/We hereby authorize the collecon agency the right to report this account
as delinquent to all the Credit Bureaus.
Signature of Understanding: I have read and understand the financial policy. By signing this form, I consent to
the above terms and condions of treatment and understand that it is my responsibility for assuring that the
financial obligaon of my care is fulfilled. I hereby accept financial responsibility for all charges incurred
whether or not I have insurance coverage.
X
X
Signature of Paent or Parent/Guardian if Paent is under 18 year of age
Signature and name of second responsible party for paent listed herein
Date
Date
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
