Patient Financial Responsibility Form

Thank you for choosing us as your dental care provider. It is our goal to provide you with the highest quality of dental care possible. We ask that you please read this form thoroughly and understand your financial responsibilities prior to receiving services.

As a patient, it is your responsibility to verify your insurance, know your insurance
plan and understand your benefits. In addition, you should be sure that your dentist is listed as a participating provider by your insurance company. You are responsible for advising this office if you have a change in your dental coverage prior to your appointment. We are not responsible for invalid dental insurance information. If your claim is denied due to incorrect personal/insurance information or your coverage was terminated at the time services are rendered, you will be solely responsible and billed for the full amount of your office visit and/or any procedures rendered.

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Dental insurance is designed to help offset the cost of dental care. Most dental plans do not cover 100% of your cost of treatment. Insurance estimates, quotes and pre-treatment estimates assist you in determining your approximate out-of-pocket expenses. Many variables exist from carrier to carrier (i.e., deductibles, annual maximums, allowable fee limitations, non-covered procedures and other restrictions), therefore we cannot guarantee any estimated charges. The amount of reimbursement is determined by your insurance carrier. You will be expected to pay your estimated portion on the day services are rendered.

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WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER, AND CARE CREDIT. There is a $25 service charge on all returned checks.

Filing insurance claims is a courtesy we offer to our patients. We will file the appropriate claim forms with your insurance company, provided you supply us with documented evidence of coverage. However, you are responsible for any amount not covered by your insurance, whatever the reason. If you do not have dental insurance at the time of service you are financially responsible for all dental procedures and fees for services rendered.

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Failure to remit payment within 90 days for any amounts deemed patient responsibility may result in your account being referred for collection activity and you will be responsible for any additional fees incurred as a result.

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We respectfully ask that you give us a minimum of 24 hours notice to cancel or reschedule your appointment. Please help us serve you better by keeping scheduled appointments.

We hope this information has been helpful. As always, feel free to ask any member of our staff for clarification on services, billing and insurance.

I acknowledge that I understand the terms of this form and assume full financial responsibility for all unpaid dental services rendered on my behalf or my dependents, with or without the use of insurance coverage.

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