I have received the information on the questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the Dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status I will inform the Dentist as soon as possible.
I authorize the insurance company indicate don this form to pay the Dentist all insurance benefits otherwise payable to name for the services rendered. I authorize the use of this signature on all insurance submissions.
I understand that the office will try to calculate my percentage of payment due at the time of the service as close as possible. Example: the deductible, copayment and annual maximum per calendar year. I understand that in the event that there is a remaining amount not paid by the insurance I will receive a billing statement which would be due for payment to the dental office. I understand that in the event the balance becomes over 90 days past due my account may be forwarded to a collections agency.
I authorize the Dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by the insurance and that payment are due at the time of the treatment, unless prior arrangements have been made.
FOR ALL PATIENTS TO READ:
PLEASE NOTE: For patients with insurance: IT IS YOUR RESPONSIBILITY to know your insurance plan. As a courtesy, our office tries to inform patients in advance of any co-payments that may be due. However, we are not always able to discuss this with the patient before their visit.
Also please note: There is an x-ray duplication fee, if you ever request a copy of your x-rays there is a non- refundable
$25.00 duplication fee.
IF YOU ARE UNSURE OF CO-PAYMENTS/PAYMENTS DUE, PLEASE ASK!!!!!
Financial Policy/ Authorization
*****if patient is under 18 years old, parent/guardian signature is required*****