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Insurance Policy Form

In an effort to make your dental visit as convenient as possible, we will be happy to fill out and submit your dental insurance claim for you. This will be provided free of charge. All claims are submitted electronically.

While we make every attempt to handle the insurance issues efficiently, it is the responsibility of the patient to provide us with the correct insurance information. Since there is a large number of insurance companies and hundreds of different insurance plans, there are sometimes conflicts and misunderstandings.

  • You will be given an estimate of the cost of proposed dental treatment and the amount the insurance pays, along with the amount you pay.
  • This is only an estimate. The amount you pay may be higher or lower.

The patient is responsible for payment, not the insurance company. If for some reason your insurance company does not pay the estimated amount within 90 days, then you, the patient, are responsible for payment. If you have overpaid, we will issue a refund after all insurance payments have been made.

If there are any insufficient fund or collection agency charges, the patient is responsible for payment.

I have read and understand this form.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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