Regarding Insurance. As a courtesy to you we will gladly process your insurance claim forms. Our responsibility is to provide you with the treatment that best meets your needs, not to try to match your care to insurance plan limitations. Dental insurance plans do not correspond to individual patient needs, and as such, many routine and necessary dental services are not covered even though you may need those services. We understand insurance guidelines can be difficult to understand and overwhelming at times. Fortunately with the information provided to us by you and your insurance company we are able to provide some assistance in estimating your insurance benefit. However, your insurance company makes final determination once treatment is completed and the claim is submitted. Your insurance is a contract between you and your insurance company; therefore, all charges are your responsibility. All insurance co-pays and deductibles must be paid at the time of service. In the event that your insurance company has not paid your account in full within 60 days, the balance may be transferred to your account. Your complete, updated insurance information must be presented at the time services are provided. We would be happy to discuss our charges and how they relate to your particular situation. We also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. I realize I am financially responsible for all charges incurred, regardless of insurance coverage. I am aware past due accounts will be subject to a charge of 1 1/2% per month interest. I am responsible for all collection costs incurred by the dental office. Regarding Appointments Your reserved time in our office is important. We understand that sometimes it is necessary to change your appointment so we ask that you kindly give us a minimum of 2 business days notice. Without this notice, we are unable to offer treatment to other patients that may have needed our care. If 2 or more appointments are broken in a 12 month period without 2 business days notice, a cancellation fee of $50 may be applied to your account and if necessary, all future appointments will be canceled and patients will be placed on a “priority list” for their next visit. Thank you for understanding our Financial Agreement. Please let us know if you have any questions or concerns. I have read the Financial Agreement for...
Regarding Insurance. Premiums and net costs of insurance taken out wholly or partially with Affiliates of the Contractor shall be recognized only insofar as they are competitive compared to insurance companies which are unconnected to the Contractor. It shall not be considered payments performed as a result of Hedging contracts.
Regarding Insurance. It’s wonderful that you have dental insurance to help cover part of the cost of your dental care. However we always recommend treatment based on your dental needs, not based on insurance coverage. Dental insurance is a benefit used to assist you, not to dictate necessary treatment. We do accept assignment of insurance benefits, however, we do require your estimated portion of the bill to be paid at the time of service. Our practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. If you have insurance for which we are not an in‐network provider, you are responsible for any remaining fees after the insurance company has made payment. Regarding Secondary Insurance, we will be happy to file secondary insurance free of charge for you. If you have secondary insurance, please let us know the carrier’s information before the primary claim is filed.
Regarding Insurance. We participate in a number of PPO and Group Benefit plans and if your insurance is one of those plans we do accept assignment. Any deductibles, co-insurances or co-pays are due at the time of service. We need a copy of your insurance card prior to treatment so that insurance benefits can be verified. If we do not participate with your particular plan, we will be happy to bill your claim for you, but payment for services is due in full at the time of treatment. Your insurance company will in turn reimburse you directly. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 days, you will be billed for that balance. Any balances over 60 days old will be subject to an interest fee of 1 ½% of the balance due compounded monthly. You will be responsible for any charge denied by your insurance company deemed not medically necessary and/or not covered. Charges reduced by Usual and Customary Ratings will be evaluated and possibly charged to you as well. We do not accept assignment on Medicare patients, but we follow the Medicare Limiting Charge fee schedule, and bill Medicare on your behalf. You will be responsible for any collection or attorney’s fees should your account require collection efforts outside our office. Any questions you have regarding this agreement should be directed to the Accounts Receivable Coordinator. Our office MUST be notified 48 hours prior to your scheduled appointment or you will be charged a cancellation fee. A new patient fee will be $250.00 and must be paid BEFORE an additional appointment will be scheduled. A return patient fee will be $100.00. . Initial
Regarding Insurance. We may accept assignment of insurance benefits. The balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you give us your insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 45 days, the balance will automatically be transferred to you as the guarantor. Please be aware that some, and perhaps all of the services provided may be non-covered services and not be considered reasonable and necessary under the Medicare Program and/or other medical insurance. All co-pays and deductibles are due prior to treatment. In the event that your insurance coverage changes to a plan where we are not participating providers, refer to above paragraph. Other Fees (request for medical records) Medical Leave Forms $25
Regarding Insurance. This office will file on your behalf insurance claims for endoscopy procedures upon receipt of necessary insurance information. This is a service that we provide, but please remember that you may be ultimately responsible for payment if your insurer or health plan does not pay in full.
Regarding Insurance. This office will file insurance for dental procedures upon receipt of necessary insurance information. This is a service that we provide, but please remember that you have the contract with your insurance company and are ultimately responsible for payment. We cannot accept responsibility for collecting from your insurance company nor negotiating a settlement on the disputed claim. However, our insurance coordinator is available if you need assistance. Remember, you are the holder of the contract. It is your responsibility to make sure you understand the contract between you and your insurance company, and you know your benefits for the policy. This is not our responsibility. After 30 days, if your insurance company has not rendered payment, your account will be delinquent and considered for collections. If this should happen we will no longer file your dental insurance for you or any of your families future dental visits.
Regarding Insurance. It is important to understand that the insurance contract is between the insurance company and you, the insured. Our office will gladly submit your insurance claim to your insurance carrier, as a courtesy to you. At the time of treatment, the patient/guarantor is responsible for the estimated portion that the insurance does not cover. If for some unforeseen reason your insurance carrier has denied or not made payment within 60 days, the patient/guarantor is responsible for the balance in full. Due to pending claims and patient privacy issues, we do not always know how much an insurance company has already paid to another office or specialist and the balance remaining on a yearly maximum. Pending treatment will default to a standard office fee, once your insurance policy has reached its maximum. Dental insurance was not designed to pay for all dental care. Our goal is to maximize the amount of your care covered by your insurance benefits. However, it is important to understand that treatment recommendations made by Xx. Xxxxxx are based on an individual’s needs, and not necessarily based on what insurance coverage is available.
Regarding Insurance. We may accept assignment of insurance benefits after you provide your insurance information, an original claim form fully completed, and a copy of your insurance policy. Insurance is a contract between you and your insurance company. We are not a party to this contract. Our office is happy to assist you in filing claims, and we assume you understand your insurance policy; therefore, please ask our front office staff to interpret your insurance policy if you are not clear on the benefits due you on each dental procedure or if you are not clear on dental procedures not covered under your policy. You must pay your co-payment including any deductibles at time of treatment in order for our office to file your dental claim with your insurance company. The balance is your responsibility whether your insurance company pays or not. If your insurance company has not paid the claim within 45 days, you will be expected to pay the remaining balance in a timely manner. If your account becomes delinquent, our office will reserve the right to not accept assignment of insurance benefits on future claims unless you provide a credit card with authorization to bill that account for the balance not paid by your insurance company. Late payment charges are added to unpaid accounts after 60 days from the date of treatment.
Regarding Insurance. We are contracted with most insurance carriers, and will accept assignment of benefits, but in all cases we require that the guarantor, the person who is financially responsible, is personally liable for all amounts not covered by insurance. Please provide policyholder information: Name of policyholder Policyholder Date of Birth It is your responsibility to understand and comply with terms of the insurance agreement you (or you and your employer) have purchased. You contract an insurance company to help you pay your healthcare bills, and insurance companies contract with us to provide quality healthcare and to file claims for you—we are not contracted to act as fiscal intermediaries between you and your insurance company to ensure payment. If your treatment involves laboratory tests, radiology services, other diagnostic testing, or hospitalization, it is your responsibility to let us know where you can have these services provided. We are happy to pre-authorize tests and treatments that our physicians have ordered once you have given us the necessary information. Obtaining referrals to our office is your responsibility. Please be aware that some, and perhaps all, of the services provided may be non-covered services or may not be considered medically necessary under the Medicare Program or by other medical insurance companies. In these cases, you are responsible for all charges. If you do not have insurance coverage in effect at the time of service, please be prepared to make payment in full at the time of your visit. Payment arrangements must be made prior to services, if you are unable to pay the full amount due.
