Insurance holders:
Our dental team will be happy to bill your insurance carrier. Due to continually changing insurance regulations, benefits and deductibles, we are only able to approximate your insurance payment. Approximated insurance payments are not guaranteed. We do expect payment of any uncovered services, deductibles or co-payments.
Your insurance policy represents a contract between you and your insurance company. It is your insurance company that makes the final determination of your eligibility and benefits. If your insurance company pays you directly, you are responsible for full payment.
By signing this document, you acknowledge that you have read and understand the stated guidelines and agree to comply with the outlined payment terms.
I authorize the dentist to release all information necessary to secure the payment of benefits to my insurance company.
I authorize my insurance company to pay the dentist all insurance benefits for services rendered in accordance with dentist-insurance company contract.