Patient Insurance Form

Please be advised insurance is a great benefit to patients and it is very important you are aware of the limitations in your insurance plan. All preventative and basic procedures will be considered under your insurance percentages. Patients are expected to know their insurance policies and pay any co-pay or deductible at time of service.

All major work must be paid in full before final placement of the completed product. Please discuss normal payment arrangements such as pre-payment plan and or/ Care Credit prior to your appointment.

If you have two insurance contracts, we will be happy to bill both provided that we have the correct information. Your insurance company has six weeks to process your claim and remit payment to us. If there is no response from your insurance company after six weeks we will then bill you for the full amount and you will then be reimbursed once insurance does pay.

Please provide us with any NEW or CHANGED insurance information prior to your appointment. Thank you.

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.