Common Contracts
1 similar Financial Agreement contracts
Financial Agreement / Office PoliciesFinancial Agreement • April 30th, 2016 • Midlothian
Dental Insurance: Your insurance is a contract between you and your insurance company. There is no direct relationship between our office and your insurance company. Your insurance benefits are determined by the type and design of plan chosen by you and/or your employer and we are not a party to this contract. We have no control over the terms of your contract, the method of reimbursement, or the determination of your benefits. Some and perhaps all of the services can be defined by your insurance company as ”not covered”, “denied”, or “over UCR”. We will file your primary dental insurance claims as a courtesy to you. We do not guarantee payment and are not responsible for providing you with the plan limitations, exclusion, and provisions determined by your insurance company. You agree to be responsible for payment of all services rendered on behalf of myself and/or my dependents. If your insurance company requires a referral and/or preauthorization, you are responsible for obtaining it
