Allard Station Dental Plan Information Form

Dental Plan Information
Primary Plan (For children: the parent who’s birth month comes first in the year is the Primary Plan):
Group #
Insurance Company:
Id or Certificate #
Employer/Company Name:
Subscriber/Policy Holder's Name:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
Will this plan allow payment to the Dentist?
Secondary Plan
Group #
Insurance Company
Id or Certificate #
Employer/Company Name:
Subscriber/Policy Holder's Name:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Will this plan allow payment to the Dentist?
Financial Policy

OPTION 2 - Direct Billing: • For direct billing insurance providers, a credit card must be on file for outstanding amounts owing after insurance claims. Each insurance provider has fee guides to calculate your coverage. Insurance providers pay a percentage of their fee guide, not a percentage of our office fee guide. Because of this, it is impossible to estimate exactly how much your Insurance provider will reimburse you. We strive to accurately estimate for reimbursement; however, there may be a balance owing. For balances owing under $100, your card will be automatically charged. For balances over $100, we will attempt to contact you, and mail you a receipt with a copy of the Explanation of Benefits from your Insurance provider.
I agree to the above financial policy and authorize Allard Station to apply any outstanding balance on my account, not covered by my Insurance provider, to the credit card listed below:
Cardholder Name:
Authorization Signature:
Mode of Payment:
Card #:
CC Code On Back:
Expires:
Should be Empty: