Financial Consent Form

Patient Name

Thank you for choosing our office for your dental healthcare needs. Dr. Steinberg is an unrestricted, out-of-network provide, which allows us to provide a wide array of treatment option using premium materials without the rigid limitations of insurance company policies. Financial arrangements must be made in advance. Patients who carry insurance understand that all dental services are charged directly to the patient and that he/she is personally responsible for full payment. Our office will help prepare the insurance claim forms or assist in making collections from your insurance company and will credit any such collections to the patient’s account.

All emergency services or any services performed without previous written financial arrangements must be paid in full by cash, VISA MasterCard, Discover or CareCredit at the time of service.

For our patients with insurance we conveniently offer two options.

Please choose one of the following options:

We can file your insurance claim and ACCEPT ASSIGNMENT. We will accept your estimated portion at the time of service and we will wait to receive the benefit payment directly from your insurance company. Your credit card will be encrypted to automatically settle any remaining balance after the insurance benefit is paid. If your insurance company fails to pay your claim in 45 days the balance will be charged. We can file your insurance claim and NOT ACCEPT ASSIGNMENT. Your insurance company will pay the benefit directly to you and we will accept full payment at the time of service.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Name/Signature

Date:

Your information will be encrypted.