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Insurance and Medical History Form

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HIPPA Acknowledgment Form


The office is in network with several insurance companies; please contact us if you have questions regarding your particular plan. As a service, we will gladly process your claim forms if you have dental insurance. Also as a courtesy, our office is pleased to accept the assignment of benefits from all dental insurance carriers that allow for it. If applicable, you will be expected to pay the estimated co-payment at the time of your visit. We will know with most insurance plans following verification of benefits what that co-payment will be. We ask that you carefully read your policy to be sure that you are fully aware of any restrictions that apply to the services provided.

Please keep in mind, any estimate we provide for you, is only an estimate and is based solely on the information your insurance company provides us with. Also, please note that you are fully responsible for the whole dollar amount of all fees charged, independent of insurance involvement and that we are doing this as a courtesy to you to minimize your out of pocket expense. If your company refuses to assign benefits then payment in full is due when treatment is rendered. We will be happy to process your claim so that you can receive reimbursement directly from your insurance company.

Payment (or co-payment if you have insurance) is expected at each visit with cash, check, or credit card. We are happy to offer an incentive for treatment costing over $800.00 or that will involve multiple visits. The office will give you a 5% savings courtesy for payment in full at the time treatment initiates utilizing one of the above methods. Otherwise you may pay as you go, breaking up your payments with the balance being satisfied on the day when your treatment is completed.

We are happy to work with you to ensure that you are able to take full advantage of your benefits if you have dental insurance. In order to provide the highest quality care on a sound basis, we have developed a full range of convenient payment options for you to choose from. Prior to the commencement of treatment, fees and financial arrangements will be discussed with you

In addition, we have a great payment plan, whereby we can extend to you, interest free financing for up to 12 months. It’s very simple. It takes just a few moments of your time, and a quick phone call from us to see if this payment plan is right for you. There’s no money down and you don’t have to wait to begin your treatment. Longer payment plans can be set up if necessary with a low-rate of interest to be charged.