PRIMARY CARRIER
SECONDARY CARRIER
We are committed to providing you with the highest quality lifetime dental care, so that you may attain optimum oral health. The following is a statement of our Financial Policy, which we require that you read, agree to, and sign prior to any treatment. We are pleased to discuss our professional fees with you at any time. Your clear understanding of the Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, Financial Policy, or your responsibility upon arrival at your first appointment.
ADULT PATIENTS
Adult patients are responsible for full payment at time of service.
MINORS ACCOMPANIED BY AN ADULT
The adult accompanying a minor, his/her parents or guardians are responsible for full payment at time of service.
INSURANCE
We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company.
Please understand that we will provide an insurance estimate to you, however, it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefits will determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time. If you are paid by the insurance company instead of our practice, you then become responsible for the total account balance and payment would be expected immediately.
We ask that you sign this form and/or any other necessary documents that may be required by your insurance company.
DEDUCTIBLE/CO-PAYMENT
We may ask that you pay the deductible and co-payment, which is the estimated amount, not covered by your insurance company, by cash, check, credit card or Patient Financing (Care Credit) at the time we provide the service to you.
By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I authorize the release of records and x-rays relevant to dental treatment and request that they be sent to Abington Family Dentistry, P.C.
Address: 314 N. State Street, Clarks
Summit, PA 18411
Fax: 570-586-5857
Email: abingtonfamilydentistry@frontier.com
Phone: 570-586-6500
By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.