Rodney G Sigua, DDS, MAGD, PLLC
Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand however, that the contract regarding your dental benefits is between you. your employer, 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 reimbursed by your insurance company. The following provisions identify our policies governing insurance claims.
I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO THE DOCTOR.
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