Patient Financial Responsibility Form

We are pleased to assist you with any dental insurance. If you have dental insurance, please be aware that insurance quotes are an ESTIMATE only. Coverage may be different if your deductible has not been met, annual maximum has been met, or if your coverage table is lower than average.

Patient Financial Responsibilities

• The patient's parent or guardian is fully responsible for payment of care regardless of if you have insurance or not.
• As a courtesy to you, we will bill your insurance company for services rendered.
• Some procedures or treatments may not be covered by your insurance plan due to employers contract with the insurance company. The parent and/or legal guardian are responsible for the payment of all services rendered in this office, with or without insurance.
• Any remaining balance left after the insurance has paid their portion is the responsibility of the parent or guardian.

• Copay and deductibles are due at time of service, no matter who brings the patients to the appointments.  INITIAL HERE ______

• I am responsible for providing a copy of my current insurance card to Dr. Lunken's office. If my current insurance is incorrect it is my responsibility to provide that information the day of service. If I fail to provide my insurance information on the day services are rendered I understand that I must PAY IN FULL the same day that services are rendered.   INITIAL HERE ______
  
  

• You are responsible for taking part in the recovery of your insurance claim.  After 45 you will be responsible for PAYMENT IN FULL for any oustanding balance.  INITIAL HERE ______

I acknowledge that I am fully responsible for payment for all treatment my child/children receive in this office. I understand my insurance carrier may deny part of, or not cover, my claim for these services. I understand that providing Dr Lunken with my insurance information is my responsibility. I understand that my insurance is a contract between myself and my insurance carrier and that Dina Lunken DDS has no part in this contract.

I understand the terms of this form and accept full financial responsibility with or without the use of dental insurance. The undersigned also agree(s) to pay all collection cost incurred, in an amount not to exceed fifty percent (50%) of the unpaid balance, should any unpaid balance be referred to a collection agency, in addition, should any unpaid balance due be referred to an attorney for litigation, all reasonable attorney fees and court costs shall be paid for by the undersigned as allowed by the court.

The office of Dina Lunken DDS will not be able to split invoices to multiple parties. We will bill the undersigned of this form and it will be their responsibility to inform for them to pay their portion. I understand that my dental insurance carrier may pay less than the actual bill for services.

Notices and Patient Communications:

You expressly consent to be contacted, by DINA LUNKEN DDS or anyone calling on its behalf, for any and all purposes, at any telephone number, or physical or electronic address you provide or which you may be reached, including any wireless telephone number. You agree that DINA LUNKEN DDS may contact you in anyway including calls or prerecorded or artificial voice or text messages delivered by an automatic telephone dialing system or email messages delivered by an automatic emailing system.

You expressly acknowledge that this consent cannot be revoked without prior agreement and acceptance by us. You agree to promptly notify us at any time your contact information changes.