Andrea N. Leinassar, D.D.S.
Scott Leinassar, D.M.D.
General Dentistry

2311 Hwy 208   *   P.O. Box 305 Smith, NV 89430   *   Telephone (775) 465-2388

Financial Agreement

Please fill out this form and hit the Submit button at the bottom of the page.
It will be securely sent to our office.

  1. I understand that although I may own one or more insurance policies, I, not the insurance companies, am responsible for payment of all charges incurred for my treatment by Andrea N. Leinassar D.D.S. and/or Scott Leinassar, D.M.D., and also that my account will be paid at each appointment unless I make other arrangements with this office. I will pay in full the charges in the following manner:
    *Fees May Apply
    *Fees May Apply
  2. Balance is due and payable in full 10 days from statement date. A finance charge of 2% per month, 24% per year or a minimum of $2.50 will be charged to accounts with a balance of over 30 days. A service/re-billing fee of $7.50 will be charged to the account when no payment is made or terms of the contract agreement are not met. Please contact our office if you are unable to meet the above terms. Allowances will be made while processing insurance claims up to six weeks. A fee of $25.00 will be charged on all returned checks. I understand that if my account is assigned to a collection agency, that the collection agency will charge a commission or fee that may be as much as %50 of the amount I owe. I understand that if my account is assigned to a collection agency that Andrea Leinassar, D.D.S. PLLC may add the amount of the collection agency's commission or fee to the amount that I owe, and I agree to pay that additional amount.
  3. I understand and agree that in the event legal action is commenced to enforce my obligations hereunder, that I will pay court costs and reasonable attorney's fees.
  4. A 24 business hour notice is required in the event you need to change your appointment day or time. If 24 business hour notice is not given you will be charged a $50 "Late-Cancel/No Show" fee.

Patient, Parent, or Guardian if Patient is a minor

Authorization to Pay Benefits to Dentist:

I hereby authorize and assign all payments directly to Andrea N. Leinassar D.D.S. for all dental benefits otherwise payable to me for services. Consent is hereby granted to use this digital or photostatic copy as equally valid authorization.

Patient, Parent, or Guardian if Patient is a minor

Processing