Financial Responsibility

Financial Responsibility Form
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Assignment of Benefits and Financial Responsibility

Our office will accept assignment of benefits from your primary insurance company with the following provisions. It is important to understand that the contract regarding your dental benefits is between you, and your insurance company. The obligation you have with our practice is to pay for treatment regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.

1. Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the transaction. With your insurance information we can only estimate payment. Any discrepancy in fees actually paid will remain your responsibility. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement. By having our office process your insurance forms, it is important that you understand that this does not eliminate you from financial obligation for your treatment.

2. We require you to sign this form and/or any other necessary assignment documents that may be required by your insurance company. This instructs your insurance company to make payment directly to our office. By signing this form you are authorizing the doctor to deposit any check received that is made out to you.

3. We require you to pay the co-payment, which is the amount not covered by your insurance company, at the time we provide service to you. We do not accept secondary insurance as payment.

4. Insurance payments ordinarily are received within 30 days from the time of billing. If your insurance company has not made payment to our office within 60 days we will ask you to pay the balance due. You will be responsible for seeking reimbursement from your insurance company at that time. We do not call your insurance company.

5. Please be aware that finance charges will be applied to all account balances not paid within 60 days. Please assist us in receiving prompt payment from your insurance company and in clearing up any remaining balance to avoid any finance charges on your account.

6. Our office will not enter into a dispute with your insurance carrier over any claim. I have read and understand the above terms and conditions. I authorize my insurance company to pay my dental benefits directly to the doctor. I also authorize my insurance company to mail all checks to my dentist even though my policy requires they be made out to me. I authorize the doctor to initiate a complaint to the insurance commission on my behalf for any claim that is not paid within 30 days.

I have read the Financial Responsibility Policy *