Patients with dental insurance must provide accurate and complete insurance information so we may assist you in filing your dental claims promptly. You will be required to pay your estimated portion the day of treatment. Remember that professional services are rendered and charged to the patient and not the insurance company.
Insurance reimbursement is a contract between you and your carrier. You are responsible for payment of your account within the usual limits of our credit policy. If your insurance does not pay within 60 days, we shall expect payment in full from you.
If you have any questions, we will assist you. Your eventual reimbursement will be determined by your insurance
Assignment of Insurance Benefits: I hereby authorize Edgewater Dental to submit claims to my insurance carrier for all services rendered. I direct third party payers (insurance companies) to issue payment directly to Edgewater Dental.
Authorization to Release Information: I authorize the release of any information concerning my or my child's healthcare, advice, and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
Financial Responsibility: I understand that this is my responsibility to provide complete, accurate and timely information on my insurance coverage. In the event that my insurance coverage does not pay, for any reason, I understand that I will be financially responsible for the dental services.
I understand that I am responsible for all costs of dental treatment, whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions.