Financial Agreement

Please correct the errors described below.

Payment in full is due on the day of surgery, if you do not have any insurance.

In cases of divorced parents, the parent bringing the child will be deemed responsible for payment.

If you do have insurance we will attempt to call your insurance to access your benefits and estimate your portion due the day of surgery. The actual patient responsibility may vary depending on the amount your insurance company pays. Insurance companies do not guarantee payment or the amount they will pay. If we are unable to access your insurance benefits, you will be responsible for the entire fee. You are responsible, however, for all fees incurred in the event insurance is denied. All co-pays & deductibles are due on the day of surgery.

If your insurance is out-of-network, you are responsible for full payment at time of surgery. We will will do the courtesy of billing your insurance provider to see if there is any coverage for your procedure. Should there be coverage, we will issue you a refund check for the amount the insurance pays.

I understand I will be responsible for any amount not paid by my insurance company.

Estimates are based on the plan benefits that have been released to us and are subject to the conditions of the plan on the day the charges are incurred. Any amounts quoted are only estimates and not a guarantee of benefits paid by your insurance.

As an accommodation to you we will submit a claim on your behalf. Please remember the contract is between you and your insurance company, not our office and your insurance company. If you have questions regarding your insurance plan we do recommend you contact your insurance company directly or contact your human resource department of the employer/company offering your insurance benefits.

Occasionally, dental insurance companies require a denial from your medical carrier before processing your claim. If this denial is not received in our office within 30 days of the date of surgery you will be held responsible for the balance due.

If payment from your insurance is not received within 60 days of the date services are rendered, we reserve the right to bill you directly and hold you responsible for the entire balance due.

If insurance coverage is denied, your account must be paid in full within 30 days of invoice. Accounts not paid within 30 days will be subject to a rebilling fee on the account balance. Any balance not collected within 60 days will be referred for collection/court with attorney fees assessed.

I understand and agree to the above financial policy.

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.

Your information will be encrypted.