Payment Method-Dental Insurance Policy

Select from the following options:*

I will be paying out-of-pocket and agree to make all payments (unless prior arrangements have been made) at the time services are rendered per office policy.My child(ren) are covered under a dental insurance policy and I agree to give your office any necessary information needed for billing purposes.

We are happy to assist you in filing the necessary forms to help you receive the full benefits of your coverage. The insurance relationship constitutes an agreement between the carrier and the patient. As such, we can make no guarantee of estimated coverage or payment. However, please know that we will do everything possible to see that you receive the full benefits of your current policy.

Subscriber Name:*

Date of Birth:*

Date

Subscriber ID/SSN:*

Group/Employer Name:

Group Number:

Insurance Name:*

Insurance Telephone Number:

Military Parent - Paygrade:

Military Parent - Commanding Officer:

Please check the following to acknowledge:*

I understand that I am responsible for and agree to pay all fees for my child's/children’s dental treatment.I agree to pay the total cost of dental services rendered on the date of service if my child/children do not have dental insurance benefits.

Please check the following to acknowledge:*

I authorize release of any information concerning my child's/children’s healthcare recommendations and treatment for the purpose of evaluation and administering claims for insurance benefits.I authorize payment of insurance benefits directly to Lauren L. Gutenberg, DDS, MSD. and/or Steven J. Niethamer, DMD.I understand that my dental insurance benefits may be less than the fees for dental services and may not pay the fee charged in full.I understand that because you cannot guarantee my EXACT insurance coverage, there may be a balance remaining after insurance payment is received.Please Note: It is NOT to be assumed that Financial Responsibility is held by the individual that carries the insurance policy but instead is the responsibility of the legal parents/guardians.I understand that I am responsible for and agree to pay all fees for my child's/children’s dental treatment.I agree to pay any applicable deductibles and estimated copayments on the date dental services are rendered. I understand that not all dental treatment received may be covered by my insurance plan and I agree to pay for any non-covered services on the date the dental services are rendered.I agree to pay the total cost of dental services rendered on the date of service if my child/children do not have dental insurance benefits.

Relationship to Patient*

Parent/Guardian Signature:*

Date:*

Date

Name of Parent/Guardian*

First NameLast Name

Payment Method / Dental Insurance Policy Information