Thank you for choosing the office of Dr. Byrne to provide for your orthodontic needs. As a special service to you, we will assist in filing insurance claims so that you might receive the full benefit available from your insurance coverage. We permit you to use your orthodontic benefit to lower your portion of the cost of orthodontic treatment, rather than paying the full fee upfront and waiting for reimbursement from the insurance company. This allows you the financial freedom of paying only your part of the treatment fee while we accept direct payment from your insurance company to our office. In relieving you of this financial burden, we allow ourselves to be very vulnerable to the insurance agency; therefore, we have set some guidelines and limitations that must be adhered to.
We can not be held responsible for knowing all the peculiarities and requirements of all insurance companies we deal with. It is YOUR responsibility to become familiar with your own policy. If there is a peculiarity about your insurance company of which you did not inform us, and it results in an underpayment of estimated benefits, we will not be held responsible, and the unpaid portion will amount will be applied to your portion of the account.
CHANGE IN BENEFITS, ELIGIBILITY OR CARRIER
- At any point in treatment, if you change jobs, or become ineligible for orthodontic benefits, you must notify us immediately and we will average any remaining benefits originally anticipated into your monthly payments.
- At any point in treatment, if your employer changes insurance carriers, you must notify us immediately. If the new policy has orthodontic benefits, you must forward a new form to us so that we may file a claim with the new carrier. If the new policy does not have orthodontic benefits, we will be averaging any remaining benefits, originally anticipated into your monthly payments.
INTENTIONAL OR UNINTENTIONAL WITHHOLDING OF BENEFITS
When benefits are assigned directly to this office, if the insurance company sends a check to you in error, we will hold you responsible for immediate and complete reimbursement. Should you receive a check from your insurance company, mail or bring it with you to the office. Do not deposit it or cash it. Any attempt to withhold insurance funds received by you in error will result in immediate termination of this insurance agreement and we will hold you directly responsible for the balance of the payments due.
- At the conclusion of treatment, if the insurance company has not paid the entire benefits available, we will hold you directly responsible for payment of the entire account before orthodontic appliances are removed.
- At any point in treatment, if the insurance company becomes uncooperative, we reserve the right to refuse to work with that insurance company and will look to you for payment of the remaining balance and you will have to settle with your insurance company.
- In the case of divorced or separated parents, if the insurance company issues payment to the non-custodial parent, the custodial parent will become responsible for immediate and complete reimbursement of that amount to this office.
I fully understand the conditions of the insurance Agreement and agree to abide by the limitations set forth. I also fully understand that I have a primary duty to pay Dr. Byrne and that I am responsible for the entire fee. I hereby authorize payment directly to Dr. Byrne.