Patient Financial Agreement

Dental Insurance Information Letter

Dear Patients:
We have prepared this letter to help you better understand the complexities of dental insurance. We do realize how confusing it can be. To begin, we would like to highlight a misconception – dental insurance was not designed to pay for all of your dental care. Most contracts have limits and/or various degrees of co-payment.

As a courtesy to our patients, we are happy to file your claims on your behalf. We will make every reasonable effort to collect covered amounts from your insurance company. Non-covered services are due at time services are rendered. All estimates quoted are based upon information provided to us by your insurance company and are estimates only, not a guarantee of payment. The patient is ultimately responsible for all charges incurred. Insurance companies are required by law to pay claims within 30 days. After 60 days of unpaid claims, we ask that you pay in full and have your insurance company reimburse you. We will be happy to provide any information or documentation you may require. The negotiation is between you, your employer, and the insurance company.

Our constant dedication is to provide our patients with the highest quality dental care. The treatment recommended by our office is never based on what your insurance company will pay; your treatment should not be governed by your insurance contract. We hope this information has been helpful.

I have read the above and understand and agree to these terms. I hereby authorize the release of any dental information necessary to process insurance claims. I authorize the payment of benefits to be directly to HAMMOND & THOMPSON DENTAL.