Common Contracts
1 similar Financial Agreement contracts
FINANCIAL AGREEMENTFinancial Agreement • October 19th, 2011
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 delinq
