Insurance Waiver

Dear Patient,

Please be advised that all dental services that we provided for you in our office will be billed to your insurance company if we are contracted with your plan. You may become the liable party should your insurance company fail to pay us for the service.

Also, please be aware of what is covered and what is not covered under your dental insurance plan. We do not pre-verify benefits unless the patient requests a pre-estimate is sent to their insurance company. A pre-estimate takes about 4-6 weeks with your insurance company.

I also acknowledge that Dr. John D. Miller, will gladly process my insurance claim, however, I must pay my estimated portion at the time of my appointment. If payment is not received from my insurance carrier within 90 Days I will be responsible for the balance due. If there is a service that is not covered by your insurance company, you will become the liable party should your insurance not pay.

I am signing that I have read, accept and understand the above insurance waiver for all my services.

DISCLAIMER: 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.