Common Contracts
1 similar Patient Financial Responsibility Agreement contracts
Patient Financial Responsibility AgreementPatient Financial Responsibility Agreement • April 25th, 2019
This letter is to inform you that Hines Family Dentistry may or may not participate with your dental plan. We will submit any claims to your dental plan, but you will be responsible for any remaining balance for all services rendered. It is important for you to understand that your procedure(s) may or may not be reimbursable by your insurance depending on your plan.
