Signed Date
Date
OoLi Orthodontics Location
OoLi Orthodontist Name
Patient Name
Address
Patient Email
Patient Phone
Financial Promissory Note Singer
Patient / Parent / Guardian Name
Patient / Parent / Guardian Email
Patient / Parent / Guardian Phone
Financial Obligation Due Date
Financial Obligation Past Due Amount
Financial Obligation Past Due Amount
This letter is to inform you of your past due balance. Your balance is now over 90 days past due. Please see your financial obligation to date, which is noted above. We are preparing to send your account to our collection agency unless you pay the above amount in full within 10 days from the receipt of this letter.
W.W. Jonathan Park, D.M.D., M.S. (OoLi Orthodontics-AZ, Tempe/PHX, P.C.) provides quality orthodontic care to our patients at a reasonable and affordable fee. We cannot continue to provide this service if our patients do not fulfill their financial obligations to us.
The above balance due includes the monthly payments not paid to date and any applicable late charges. The fee for placement of initial orthodontic appliance will also be included in the balance turned over to our collection agency; this charge was deferred and scheduled to be paid over the term of your loan. The default of your loan cause this charge to be due immediately and therefore the amount due maybe greater than your record.
Please consider the following options and choose the one that is most appropriate:
*Make a financial arrangement with our financial coordinator to bring your account current
*Make arrangement with our financial coordinator to have the orthodontic appliances removed. Any remaining balance may be turned over to the collection agency
*In the event of extreme hardship, please contact our office immediately to discuss an alternative payment plan.
I regret having to take this action.
