(Please Read & Sign Below)

As an additional service to our patients, we will be happy to accept assignment for direct payment from your insurance carrier. However, our professional services are rendered to you and not the insurance company. Therefore, you are responsible to us for the obligation of payment for your treatment. In order for us to be reimbursed in a timely manner we must have on hand:

  1. A copy of your current benefit booklet.
  2. A copy of you current benefit card or I.D.

Fees for our services are the same for all patients whether or not they are covered by insurance, unless there is a contractual agreement with a carrier. The variety of types of insurance is great. Programs established by the many companies provide coverage as little as 30% of the fees to as much as 80%. Coverage that provides 100% for everything is very rare. Dental insurance is not designed to be a PAY-ALL.

There may be a deductible involved.
There may be a feature that will limit the amount of pay out.
There are often many features of various plans that will limit or eliminate the amounts they will pay on certain procedures.

Read your policy, we will do our utmost to help you get the maximum benefit payable by you company. IT IS YOUR RESPONSIBILITY TO KNOW YOUR INSURANCE PLAN.

We cannot, under law that carries penalties as severe as suspension of license, change dates of treatment, or submit claims for treatment not rendered.

Financial obligation for the balance of payment for your dental treatment rests with you. We will make arrangement with you in advance of treatment to handle the finances relative to your specific needs. We cannot begin treatment if definite arrangements for payment have not been made.

Should you have any questions about your insurance, our office staff will be glad to assist you.

Patient Signature (or Parent/Guardian Signature if Minor)