Patients with Dental Insurance. Because we understand that dental insurance plays a role in helping many people defray some of the costs of dental care, we would like to share with you the following information about dental insurance. Please understand that our responsibility is to provide you with the treatment that best meets your needs, not to try to match your care to insurance plan limitations. Dental insurance plans do not correspond to individual patient needs, and as such; many routine and necessary dental services are NOT COVERED by insurance, even though you may need those services. In spite of what your plan says, we have found that many plans actually pay LESS than what you might expect. The benefits your plan pays are largely determined by how much your employer/union pays in premiums for the plan. The less they pay for the plan, the less you will receive. We are happy to submit your claims and help you receive the maximum benefits due you, but please understand that we cannot accept responsibility for collecting an insurance claim, or for negotiating disputed claims. For treatment that requires dental laboratory services, a minimum down payment will be required at the initial appointment. All account balances over 60 days will be subject to a finance charge of 1% per month or a minimum monthly rebilling fee, regardless of insurance status. I have read and understand the above financial policy. Regardless of insurance coverage, I am responsible for payment of all dental fees for myself and/or my dependents.
Patients with Dental Insurance. Initial Dental insurance is considered an agreement between you and your insurance company; therefore we can only estimate your dental benefits. This estimate is not a guarantee of payment by your insurance company. You are responsible for any charges your insurance company does not pay. Initial Your out of pocket portion and deductibles are due at time of service. Initial Insurance payments not paid after 60 days will become your complete responsibility. You agree to pay your full balance after 60 days from date of service. Initial A minimum of 48 hours’ notice is required for any changes or cancellations to your appointment to avoid a $50 cancellation fee. This change cannot be submitted to your insurance company. Cash or Senior Discount Smiles Dental will gladly submit your insurance claim on your behalf; however, if you wish to take advantage of our 5% cash or 10% senior discount, you will need to bill your insurance company directly.
Patients with Dental Insurance. We will xxxx your insurance company at the time of service. However, if there is a balance, it is your responsibility, whether your insurance company pays or not. All co-payments and deductibles are due at the time of service. Please be aware that some, and perhaps all, of the services provided maybe non-covered services and not considered reasonable by your insurance company.
Patients with Dental Insurance. As a courtesy we will gladly file your claims and accept assignment of dental insurance benefits provided you agree to the following: • You understand that your treatment plan is individually tailored, and is not based on your dental insurance benefits or lack of benefits. • You must provide us with an insurance card and all the information necessary to verify your coverage and file your claim. • Your insurance policy is a contract between you, your employer and the insurance company. Our relationship is with you and not your insurance company. • Although we may estimate your insurance benefits we are not responsible for their accuracy. Knowledge of benefits as well as benefit amounts, limitations, exclusion’s, waiting periods, etc. is entirely YOUR responsibility. Receiving our services indicates your acceptance of responsibility to pay regardless of our estimate. • All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment. Not all the services we provide are covered benefits. Benefits differ from one company to another. Fees for non-covered services, along with deductibles and copayments are due at time of treatment. • We do not file claims for medical insurance or more than two dental insurance companies per patient. Consent and Authorization: I authorize dental treatment and agree to pay all related professional fees. Fees not covered by my dental insurance will be promptly paid upon notification from this office. I have read and understood this document in its entirety, outlining office policies and financial policies of Acre Wood Dental. Without any reservations, I agree to abide by the policies outlined herein. Form Completed by: Printed Name First Name Last Name Date Submit Signature (Patient or parent/guardian of minor)
Patients with Dental Insurance. Your complete, up-to-date insurance information must be presented before any services are provided. It is your responsibility to make sure your insurance is active. If you get dental treatment and your insurance is not active, you are responsible for full charges at regular office fee and not insurance fee. ESTIMATED Patient copayments and deductibles are due at the time of service.
Patients with Dental Insurance. Please remember that your insurance policy is a contract between you and your insurance carrier. We do submit claims electronically to your insurance carrier for reimbursement towards your account, as a courtesy to you. We do expect patients to be interactive and responsible for communicating with your insurance carrier on any open claims. It is the patient’s responsibility to know if our office is participating or non-participating with their insurance plan. If your insurance company reimburses you directly, we will file your claims but require payment in full for your treatment at the time of service, unless financial arrangements have been made in advance with the office manager. Patients are responsible for any balances not covered by dental insurance. Any outstanding account balances not paid by insurance within 60 days becomes the responsibility of the patient. By signing this form you agree to provide all relevant and accurate information to facilitate the prompt payment of the claim by your insurance company. Our office staff will verify your insurance details, your estimated patient portion is due in full at the time of service. Failure to provide all required information may necessitate patient payment for all charges. Office Policy
