Financial Consent and Authorization for Treatment
We wish to stress that the financial responsibility for services rendered rests with the patients and his/her family, regardless of any insurance coverage; your insurance policy is a contract between you and your insurance company. We cannot guarantee payment or coverage of your claim.
I agree to be financially responsible for all charges for all services and materials not paid by my dental plan or covered by my plan if applicable. To the extent permitted by law, I consent to the dental office’s use and disclosure of my protected health information to carry out payment activities in connection with the insurance claim.
I hereby authorize and direct payment of the dental benefits, otherwise payable to me, directly to service providers at Markham Dental – General and Cosmetic Dentistry.
I agree to pay all fees and charges rendered at Markham Dental – General and Cosmetic Dentistry for myself and my family. I agree to pay all charges when presented with a statement, unless prior credit arrangements are agreed upon in writing.
I understand and agree, regardless of my insurance status, I am ultimately responsible for any unpaid balance on my account.