As a convenience for you, we submit your insurance forms although we cannot be considered your insurance company. We cannot guarantee how your insurance company will actually pay for your dental services. Ultimately, it is your responsibility to contact your insurance company directly, or find out from your employers HR department the specific or definitive information on the services provided by your dental insurance policy. Patients with insurance are responsible for co-payments at the time that services are provided. We accept cash, checks, and MasterCard, Visa, or Discover.
Insurance Agreement: To avoid misunderstandings and to facilitate the processing of you insurance claim, we ask you to read and sign this statement before we agree to accept assignment directly from you insurance company.
I understand that I am responsible for the payment of all treatment fees on my account.
If my insurance company fails to make full payment and there is an outstanding balance within
60 days, I am responsible for the full amount owed to The Dentists Collaborative at that time.
Name: _____________________________ Date: _________________
(please print out and sign this form)
