Financial Policy Form

This statement is to inform you of our financial policy. We are committed to providing you with the highest quality of dental care utilizing only the best materials and education available. In our process of doing so, we have formulated a financial policy to continue to provide excellent service to you and minimize our administrative costs.

For those patients with dental insurance, as a courtesy, we will assist you in processing your insurance claims. You may direct your insurance company to pay your benefits directly to our office by signing the authorization on the Assignment of Benefits Agreement below. Your co-payment amount is due when services are provided.

Payment is due at the time service is provided. Our office accepts, Cash, personal check, MasterCard, Visa, and Discover. Financing options are available. Please ask for details.

All incurred charges are ultimately the responsibility of the patient regardless of insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, and not with your insurance company. Your insurance plan is a contract between you, your employer, and the insurance company. Our office is not a party to that contract or any restrictions.

Returned checks and balances older than sixty days may be subject to collection fees and finance charges at the rate of 1.5% monthly. Additionally, charges may be incurred for broken appointments and appointments cancelled without twenty-four business hours advance notice.

If you have any questions regarding our financial policy, please do not hesitate to ask. We are committed to providing you with the most positive experience in dental care.

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.

Assignment of Benefits Agreement

Our office will accept an assignment of benefits from your insurance company with the following provisions. It is important to understand that the contract regarding your dental benefits is between you, your employer, and your insurance company. The obligation you have with Pikes Peak Dental to pay for treatment, regardless of the amount that may or may not be reimbursed by your insurance company. The following provisions are our policies concerning insurance claims.

• Although we are willing to complete insurance information forms and submit a claim on your behalf, we do not accept responsibility for the outcome of the processing of that claim. Completing insurance forms is a courtesy we extend to you in an effort to maximize your insurance reimbursement. By having our office process your insurance forms, it is important that you understand that this does not eliminate your financial obligation for your treatment.
• We require you to sign this form and other necessary assignment documents that may be required by your insurance company. This instructs your insurance company to make payment directly to Pikes Peak Dental.
• We require you to pay the co-payment, which is the estimated amount not covered by your insurance company, at the time we provide service to you.
• Our office does not guarantee that your insurance company will pay for treatment you receive from Pikes Peak Dental. We perform routine insurance billing procedures upon verification of coverage. However, if your claim is denied, you will be responsible for paying the full amount at that time.
• Our office will not enter into a dispute with your insurance company over any claim, although we will provide necessary documentation your insurance company request to sort out any questions that may arise. We will cooperate fully with the regulations and requests of your insurance company. It is ultimately your responsibility to resolve any type of dispute involving payments made or not made by your insurance company.

I have read and understand the above conditions. I hereby authorize my insurance company to pay my, or anyone covered under my insurance policy, dental benefits directly to Dr. Phong Nguyen.

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.