Financial / Insurance / Appointment AgreementFinancial / Insurance / Appointment Agreement • September 5th, 2023
Insurance – Your insurance policy may or may not follow the American Academy of Pediatric dentistry guidelines. It is your responsibility to know your own coverage and monitor your benefits. If you do not want us to provide the recommended standard of care for your child it is your responsibility to notify us.
Financial/Insurance/Appointment AgreementFinancial/Insurance/Appointment Agreement • March 8th, 2019
FINANCIAL / INSURANCE / APPOINTMENT AGREEMENTFinancial / Insurance / Appointment Agreement • August 8th, 2021
Financial/Insurance/Appointment AgreementFinancial/Insurance/Appointment Agreement • January 27th, 2015
Financial / Insurance / Appointment AgreementFinancial / Insurance / Appointment Agreement • May 10th, 2017
Insurance - We will be happy to bill your primary insurance carrier for you; however, any co- insurance and any non-participating insurance will be due in full at time of service. Although we attempt to estimate your portion due at time of service, THIS IS ONLY AN ESTIMATE. The exact full amount can only be determined after receipt of insurance payments. In the event that your dental plan determines a service to be “not covered” you will be responsible for the complete charge. In that event we will bill you, and payment is due upon receipt of that statement. If your insurance company requires a referral and-or preauthorization, you are required to obtain it. It is your responsibility to monitor your benefits and annual maximum. We will be happy to assist you with any resubmissions, but we cannot make telephone calls to the insurance company on your behalf.
