Prescription Form - Method Dental

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PAYMENT OPTIONS At Method Dental, we strive to offer a variety of payment options to our customers. We can accept payment by check, all major credit cards, and can even set up an ACH withdrawal from your bank account. Please read the below policies in their entirety to determine the best payment method for your company. CREDIT CARD It is required that all customers have a current credit card authorization on file in case payment in full is not received by the due dates outlined below. Please fill out the credit card authorization on the reverse in its entirety to activate your account. No cases will be processed without an authorization on file. Credit card authorizations on file will not be used unless we are instructed to do so on a certain day of each month, or in the case of non-payment. DUE DATE Customers are invoiced with each case processed through Method Dental. Statements, which provide a summary of all invoices created in a given month, are processed once a month on the last day of the month. Customers are required to pay the full balance of each statement by the last day of the following month (i.e. all of March's invoices are due by the last day in April). FINANCE CHARGE A finance charge of 1.5% (18% per annum) of the outstanding account balance will be charged on the last day of the month (the due date). For example: March's invoices are due April 30th. If payment in full is not received by April 30th, a finance charge of 1.5% of the outstanding balance will be applied to the account on April 30th. Finance charges are non- negotiable. UNPAID AMOUNTS AND CASH ON DELIVERY (C.O.D.) STATUS If payment is not made in full by 5th of the second month (i.e. March invoices still outstanding as of May 5th), the credit card on file will be charged for the full amount due. If for any reason, payment is unable to be made (credit card is expired, credit card is declined, etc), the customer account will be put on a “Cash on Delivery” status. This means that any cases in Method Dental's possession will not be released without cash payment made in full. All work moving forward will need to be prepaid before Method Dental will proceed with processing it through the lab. C.O.D. status will remain in force until the account balance is returned to good standing. Accounts will be given until the 15th of the second month (in our example, it would be until May 15th) to bring the account to good standing. If payment is not received by the 15th, or an agreeable payment plan is not worked out, any work received after the 15th will be refused. COLLECTIONS POLICY If at any time Method Dental determines that an account is uncollectible, we will place the account balance with a collections company and/or file a claim in court. Please note: In the event that any balance is not paid as agreed, and satisfactory arrangements have not been made for payment, the undersigned agrees to pay all costs of collection including legal fees, attorney fees, constable fees, court costs, and all charges and collection agency fees of the balance assigned, with or without suit. The undersigned also authorizes us to call them at any number provided or at a number at which we reasonably believe we can contact you, including calls to mobile, cellular, or similar devices for any lawful purpose. ACCEPTANCE OF TERMS By signing or sending a prescription (or substitute thereof) to Method Dental, the doctor agrees to abide by all terms and policies listed herein.

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