Insurance Benefits and Financial Responsibility

Insurance Benefits and Financial Responsibility
Although we try our best to estimate you insurance benefit, it is not possible for us to interpret each individual policy or know the changes that may occur to the policy at any given time. Due to the thousands of variations in plans and constant changes in benefits of each plan, it is YOUR RESPONSIBILITY to know your coverage and make sure we are contracted with your plan. Please check your coverage and any plan changes for anticipated services before your appointment.

Please remember your insurance coverage and related cost are between you and your insurance company and/or employer, NOT the insurance company and the dental office.

Because your policy is a confidential agreement between you and your insurance company, we are rarely privileged to know what procedures are covered or the specific guidelines that regulate those procedures.
I, Printed Name of Patient/Legal Guardian Responsible for Payment , understand
that in the event my insurance company does not cover any procedures rendered, it is my responsibility to pay the balance of the payment owed.
Signature of Patient/Legal Guardian responsible for Payment

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