Your dental insurance remains an agreement between you and your insurance company, and we will be happy to assist in preparing and submitting any necessary claim documents. Further, we will strive to provide estimates for all future treatment, if possible. Full payment to ADA remains your responsibility, regardless of how much your insurance does or does not pay.
As a courtesy, ADA will direct bill to my insurance. In doing so, ADA does not accept responsibility for any uncovered amounts, amounts over benefit maximums, limitations, plan restrictions, etc. I understand that ADA collects my dental coverage information only as a guideline to assist me in maximizing my benefits.
ADA advises me to contact my plan administrator or insurance company for questions regarding eligible procedures and authorization of treatment. In addition, I am advised to make myself aware of all costs involved with my dental care. ADA advises me to keep track of my yearly maximums, limitations, appointment dates, and accumulated amounts used on my dental benefit plan.
Payment is due at the time of service. I am aware that if the Advanced Dental Arts does not receive confirmation from my insurance for their exact payment, then I will be provided an estimate for my portion at the time of visit. A statement of any unforeseen balance will be provided to me.
I understand that a valid credit card on file is required if I wish to have my services billed directly to my dental insurance, payable to ADA. I authorize Advanced Dental Arts to apply any balance owing under $100.00 to be automatically debited from my credit card. For amounts owing over $100.00, ADA will contact me for payment arrangement.