DENTAL INSURANCE AND FINANCIAL ARRANGEMENTS

    Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance by our staff.

    WE DO NOT BASE OUR CLINICAL EXAM OR YOUR TREATMENT PLAN ON WHAT YOUR INSURANCE COVERS OR DOESN’T COVER.

    If you have dental insurance we will work hard to help you receive your maximum allowable benefit. In order to achieve this goal we need to take the necessary steps to understanding your insurance plan. There being so many different providers and plans, it is impossible for us to know all of our patient’s benefits. It is very important for you as a dental insurance policy holder, to be aware of the plan benefits, deductibles, and exclusions. Plan benefits can be obtained by calling your dental insurance company. We will gladly discuss your proposed treatment and answer any questions that you may have relating to your insurance.

    You however, must be aware that:

    1. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.
    2. Most insurance companies have a yearly deductible that is your responsibility to pay.
    3. Most insurance companies only pay a percentage of the cost (such as 50% or 80%) and you will be responsible for the remainder.
    4. Not all services are a covered benefit in all contracts. It is important for you to contact your insurance provider and ask if there are any clauses, or waiting periods.
    5. As a courtesy to you, our office will submit claims to your insurance provider. If for any reason the claims go unpaid you will be responsible for all charges.
    6. We will file your pre-treatment estimates, at your request, as a service to you. Please be aware that some insurance companies may not honor a pre-treatment estimate or may alter it. In all cases it will delay important dental care.

    Account balances should be paid within 30 days of the account statement. Outstanding balances after 90 days will be transferred to a collection agency unless prior arrangements have been made.

    In addition to the agreement above, the individual signed below will be responsible for all attorney and collection service fees in the event of failure to pay as agreed within this legal contract.

    I (print name) AM FINANCIALLY RESPONSIBLE FOR ANY AND ALL CHARGES ON MY ACCOUNT. I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION.

    Signature:

    Date:

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