Please fill out and sign this form. If you prefer to print a copy of this form to fill out by hand, you may do so by downloading the PDF version
. Please bring it with you to your appointment or mail it in ahead of time.
Our Policy Regarding Dental Insurance
You are fortunate to have dental insurance, whether you have purchased it or your employer has provided it for you. Though your dental insurance is your responsibility we can help! We will go the extra mile to help you maximize your benefits. As a courtesy, we will help by filing your insurance forms, which will save you considerable time and trouble. We accept payments from most insurance companies, which reduces your immediate out-of-pocket expense.
Regardless of what we may calculate your insurance company to pay, it is only an estimate. Our estimate is based on limited information obtained from your insurance company. You must understand, we cannot forecast what they will pay.
We must stress that you are responsible for the total treatment fee. Your dental insurance is not designed to pay the entire cost of your treatment, but it is intended to help cover a certain portion of the cost. A better term for dental insurance may be “dental assistance”.
Please remember, however, the financial obligation for dental treatment is between you and this office, and is not between this office and your insurance company.
I have read and understand the above.