Your dental insurance is an agreement between you, your employer and the insuring company. We are happy to bill your insurance company directly whenever possible. Please be aware that:
1. You are fully responsible for all fees associated with your dental treatment.
2. You are responsible to know your insurance: what’s covered, deductible amounts, limits, etc.
3. Notify us of any changes to your dental insurance.
4. You consent and authorize Blueridge Dental to submit claims electronically to your insurance company, to contact your insurance company for any information required related to claims, payment, coverage, eligibility, etc.
5. You must pay your estimated portion of the fees, when required at each appointment.
6. All major procedures (e.g. crown, bridge, implants, etc.) will be non assignment. We will submit these claims to your insurance on your behalf. Any reimbursement will be sent to the subscriber. Full payment is required at time of service.
7. Any fees not covered by your insurance will be your responsibility. (Most insurance carriers do not pay 100% of the treatment costs for a variety of reasons.)
8. We will allow 3 months from your appointment to receive payment from your insurance company. If payment is not received after this time, you will be responsible to pay the full amount.
Our office will submit insurance claims on your behalf to your insurance company for any contribution they may provide for your treatment. Please note that once your insurance carrier has paid their portion, or after 3 months post-treatment has elapsed, any remaining balance is your responsibility.
In an effort to limit person to person contact in our front office environment, and to keep accounts current, we are asking patients to leave a credit card on file. The credit card will be used to cover your patient portion due at time of service. Once payment is received from your insurance, any remaining balance on your account will be promptly charged to your credit card. We will notify you by email or text two business days before applying this charge.
* For security purposes, we do not collect any credit card information on this form. We will request this information when scheduling your appointment or at first visit.