Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand, though, that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with our practice is to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.

 

1. Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. Completing insurance forms is a courtesy we extend to you to maximize your insurance reimbursement. By having our office process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment.

2. We require you to sign this form and/or any other necessary assignment. Documents that may be required by your insurance company. This instructs your insurance company to make payment directly to our office. If the insurance company will not pay us directly (because doctor is not a contractual provider), then the patient will be expected to pay for services in full at the time of service.

3. The company requests to sort out any confusion or questions that arise and cooperate fully with the regulations and requests of the insurance company. It is ultimately your responsibility to resolve any disputes over payments or non-payments made by your insurance company.

4. Insurance payments ordinarily are received within of billing.If your insurance company not payment to within days,we will ask pay the balance that time. for seeking reimbursement from your company.

5. Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We perform routine insurance billing procedures upon verification of coverage. However, if your claim is denied you will be responsible for paying the full amount at that time.

6. Our office will not enter into a dispute your insurance company over claim, although we will provide necessary documentation your insurance. The company requests to sort out any confusion or questions that arise and cooperate fully with the regulations and requests of the insurance company. It is ultimately your responsibility to resolve any disputes over payments or non-payments made by your insurance company.

7. Returned checks and balance older than 60 days may be subject to collection fees and finance charges at a rate of 1.5% per month(18% annually). Additionally, our office will charge you for broken appointments and appointment cancelled without 48 hours advance notice.

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