Your insurance coverage is based on a contract between you and the insurance provider. We deal with a great number of insurance plans and due to the many restrictions and limitations placed on each patient by their insurance company, it is impossible for our office to keep track of every patients’ insurance requirements and restrictions. It is your responsibility to be aware of these.
As a courtesy we will file all dental insurance claims for you, this does not release you from your financial obligation. It is always best to check with the insurance company before seeking dental care. If your insurance has a co-payment, you are required to pay the co-payment at the time of your treatment. This is a requirement that is stated in your insurance contract. This does not guarantee that your insurance will pay your claim. You will still be responsible for the balance. If your claim is not paid, and you feel that it should have been, please contact your insurance company directly. They should be able to explain the reason to you.

All balances are due within 60 days, if your insurance carrier delays or refuses payment.

Please print this form and bring it with you to your appointment

Return to New Patient Forms