Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
INSTALLMENT PLAN AGREEMENT _______________________________________ referenced as “Responsible Party” _______________________________________ referenced as “Patient” The fees for my orthodontic treatment are calculated as follows: 1) Records Fee - $295 2) Treatment Fee – ONLY THIS PORTION IS ELIGIBLE FOR THE INSTALLMENT PLAN AGREEMENT. 3) Retainer Fee - $495 I Responsible Party agrees to pay the fees for certain orthodontic dental services rendered to Patient by BRACES BRACES, LLC in the amount of $____________ (the “Treatment Fees”) and, in order to pay the Treatment Fees, I request an installment plan (“Installment Plan”) so that I may conveniently pay the Treatment Fees over a period of ________months (the “Term”) unless earlier terminated as provided herein. I agree that each monthly installment payment will be the amount identified below as the “Installment Payment,” with one final payment, at the conclusion of the Term, of the entire outstanding balance due, if any. I understand that this Installment Plan may be terminated by Braces Braces, LLC in the event that the orthodontic plan in connection with which this Installment Plan was established is terminated by me or Braces Braces, LLC for any reason, and that, at such time, the entire outstanding balance under this Installment Plan shall be immediately due and payable to Braces Braces, LLC. I agree to comply with the terms and conditions set forth in this Installment Agreement. Even though this plan is offered with ZERO PERCENT INTEREST, because the terms of the plan require more than four (4) payments, the law requires the following “Federal Truth in Lending Disclosure”: ANNUAL PERCENTAGE RATE The cost of your credit as a yearly rate. 0.00% FINANCE CHARGE The dollar amount the credit will cost you. Amount Financed The amount of credit provided to you or on your behalf (i.e., sales price minus any down payment). Total Payments The amount you will have paid after all payments scheduled. Total Sales Price The total cost of your purchase, including down payment. $0.00 PAYMENT SCHEDULE Total Number of Payments Installment Amount $ __________________ Payment Date (each month) Not before the second (2nd) business day of the month. Terms and Conditions Are there fees associated with paying in installments? 1 There is no interest charged and no administrative fee. The Installment Plan is a free service to our customers. Please note, however, that there are fees (described below) for such things as payment extensions, returned checks, or costs of collection if you default and fail to pay the amount you owe. Please note that additional discounts may be offered to customers who pay for services in full, in advance. How much and how often will I be charged? You will be charged the Installment Amount each month for the Term (e.g., if the Term is twenty-four (24) months, you will be charged twenty-four (24) times). If any part of the Fees remain unpaid after the Term, the Term will be deemed extended, and you will be charged one additional payment during the following month for the entire outstanding balance. This additional payment is also deemed an “Installment Payment” for the purposes of this Installment Agreement. The first Installment Payment will be processed the day you sign this agreement. Future Installment Payments are processed on or after the second (2nd) day of each month after the first month unless the 2nd day falls on a weekend or a federal holiday, in which case the payments will be processed on the following business day (the “Due Date”). 2 Can I skip a payment? No. We require that all payments are made according to this Installment Agreement. Please see our Termination policy to see how missed payments can lead to the termination of your orthodontic care. What can I do if I expect to have difficulty making an upcoming payment? We have only one Installment Payment schedule. If you expect that funds will not be available for the ACH/debit/credit card on file, you must come into our office before the Due Date to change the card number on the Installment Agreement. We may be able to (but we are not required to) extend your payment date to another date within the same month. No extensions are available beyond the payment month or more than twice during the Term. There is a fee of $25.00 associated with any single payment extension granted. This fee must be paid in cash when you request the extension. What happens if my credit card does not honor a charge? If your card is declined, we will try to contact you by telephone or via email using the contact information you have provided. If you are unable to make prompt arrangements for payment, we may cancel this Installment Agreement and require that you immediately pay the entire amount of all Fees outstanding. If you do not pay, we may terminate your orthodontic treatment and refer your account to an attorney to bring legal action in order to collect the outstanding balance from you. You agree to pay all attorneys’ fees, court costs, and other costs we incur if we refer your account for the collection of an unpaid balance. Please see our Termination policy to see how missed payments can lead to the termination of your orthodontic care. What if I need to change my payment method? If you need to change the credit card on file, you must come into the office before your next Due Date to update your credit card information and sign a new authorization. Can I pay additional amounts towards the Fees so that I can pay off the amount I owe sooner? Yes. You may make additional payments at any time by contacting our office. The monthly payment amount will continue staying the same till full balance is paid. Can I make an Installment Payment by another method instead of you charging my credit card in a particular month? Changes to the method of payment are accepted in our sole discretion. No partial payments are accepted. Subject to the approval of one of our office managers, we may allow you to make a payment in cash, by check, or using another credit or debit card in lieu of an Installment Payment by making the payment in our office prior to the Due Date. What if I need to change my personal information? If you need to change your personal information on this Installment Agreement, such as telephone number, email address, physical address, or credit card billing address, it is your responsibility to contact our office with the information change. If we are unable to contact you due to outdated contact information in your Installment Agreement on file, we will be unable to alert you if we have difficulties with your payment account and this Installment Agreement may be cancelled. Please remember that a change as simple as your billing address can affect the success of your payments. Governing law. This Installment Agreement shall be governed by the laws of the State of Georgia. The parties consent to personal jurisdiction in Henry County, Georgia in connection with any claim, cause of action, or other dispute in connection with this Installment Agreement and agree to, and hereby waive any objection to, Henry County, GA as a proper and convenient venue in which to bring any such claims. If any provision of these Terms of Service is deemed by a court of law to be unenforceable, such term shall be severed and these Terms of Service shall remain in full force and effect, notwithstanding such severance.